src/main/resources/bb-test-data-v2/eob/-19990000002208_20.xml
<Bundle xmlns="http://hl7.org/fhir">
<id value="011d4b8d-a7fc-4701-879a-e64c6a02537b" />
<meta>
<lastUpdated value="2021-06-08T01:55:08.681+00:00" />
</meta>
<type value="searchset" />
<total value="43" />
<link>
<relation value="first" />
<url value="https://prod-sbx.bfd.cms.gov/v2/fhir/ExplanationOfBenefit?_pretty=true&startIndex=0&_count=20&patient=-19990000002208&_format=xml&_types=*&_startIndex=20&_excludeSAMHSA=true" />
</link>
<link>
<relation value="next" />
<url value="https://prod-sbx.bfd.cms.gov/v2/fhir/ExplanationOfBenefit?_pretty=true&startIndex=20&_count=20&patient=-19990000002208&_format=xml&_types=*&_startIndex=20&_excludeSAMHSA=true" />
</link>
<link>
<relation value="last" />
<url value="https://prod-sbx.bfd.cms.gov/v2/fhir/ExplanationOfBenefit?_pretty=true&startIndex=40&_count=20&patient=-19990000002208&_format=xml&_types=*&_startIndex=20&_excludeSAMHSA=true" />
</link>
<link>
<relation value="self" />
<url value="https://prod-sbx.bfd.cms.gov/v2/fhir/ExplanationOfBenefit/?_count=20&_excludeSAMHSA=true&_format=xml&_pretty=true&_startIndex=20&_types=*&patient=-19990000002208" />
</link>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10177349616" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10177349616" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2001-06-22" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="6273" />
<display value="ATROPHIC VAGINITIS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1H" />
<display value="Lab tests - other (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="88164" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="10.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="60.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="10.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10192733163" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10192733163" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="4" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="5" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="6" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-08-04" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2724" />
<display value="HYPERLIPIDEMIA NEC/NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1H" />
<display value="Lab tests - other (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="2" />
<careTeamSequence value="4" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="80061" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1H" />
<display value="Lab tests - other (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="3" />
<careTeamSequence value="5" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="84450" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1A" />
<display value="Lab tests - routine venipuncture (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="4" />
<careTeamSequence value="6" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="G0001" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="20.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="80.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="70.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10322272827" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10322272827" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="4" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="5" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2001-03-16" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="3814" />
<display value="NONSUPP OTITIS MEDIA NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="1" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T2D" />
<display value="Other tests - other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="2" />
<careTeamSequence value="4" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="K" />
<display value="Hearing items and services" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="92557" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T2D" />
<display value="Other tests - other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="3" />
<careTeamSequence value="5" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="K" />
<display value="Hearing items and services" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="92567" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="80.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="150.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="100.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10388016035" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10388016035" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-04-01" />
<end value="2000-04-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-10-20" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="185" />
<display value="MALIGN NEOPL PROSTATE" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="S" />
<display value="Secondary payer" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-04-01" />
<end value="2000-04-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="70.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10414946175" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="0" />
<display value="Denied" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10414946175" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-04-01" />
<end value="2000-04-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-09-15" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="185" />
<display value="MALIGN NEOPL PROSTATE" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="O" />
<display value="Other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-04-01" />
<end value="2000-04-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="70.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10532196841" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10532196841" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-11-24" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="73300" />
<display value="OSTEOPOROSIS NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2724" />
<display value="HYPERLIPIDEMIA NEC/NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="3" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="3" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-11-01" />
<end value="2000-11-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="60.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="50.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10553023028" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10553023028" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="4" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="5" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="6" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2001-03-16" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="3814" />
<display value="NONSUPP OTITIS MEDIA NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1A" />
<display value="Office visits - new" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99203" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="1" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="90.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="90.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T2D" />
<display value="Other tests - other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="2" />
<careTeamSequence value="4" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="K" />
<display value="Hearing items and services" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="92557" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T2D" />
<display value="Other tests - other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="3" />
<careTeamSequence value="5" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="K" />
<display value="Hearing items and services" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="92567" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T2D" />
<display value="Other tests - other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="4" />
<careTeamSequence value="6" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="K" />
<display value="Hearing items and services" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="92568" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="150.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="150.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="200.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="150.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10619299136" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="0" />
<display value="Denied" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="N" />
<display value="Non-assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10619299136" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-01-01" />
<end value="2000-01-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-06-02" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="72673" />
<display value="CALCANEAL SPUR" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="72871" />
<display value="PLANTAR FIBROMATOSIS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="3" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="3556" />
<display value="PLANTAR NERVE LESION" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="4" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="O" />
<display value="Other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<diagnosisSequence value="4" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="9" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="2000-01-01" />
<end value="2000-01-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="50.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10652062735" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10652062735" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-10-20" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="4019" />
<display value="HYPERTENSION NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2409" />
<display value="GOITER NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="3" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="73309" />
<display value="OSTEOPOROSIS NEC" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="4" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2729" />
<display value="LIPOID METABOL DIS NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="5" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99215" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="0" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="150.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="150.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="80.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="150.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="100.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10652596794" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10652596794" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-08-01" />
<end value="2000-08-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-09-01" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="4019" />
<display value="HYPERTENSION NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="2" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99212" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-08-01" />
<end value="2000-08-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="30.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="30.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10655264083" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10655264083" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="4" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="5" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="6" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="7" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="5" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="8" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-10-27" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2409" />
<display value="GOITER NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2729" />
<display value="LIPOID METABOL DIS NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="3" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="5641" />
<display value="IRRITABLE BOWEL SYNDROME" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="4" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="4019" />
<display value="HYPERTENSION NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="5" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1B" />
<display value="Lab tests - automated general profiles" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="80053" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1C" />
<display value="Lab tests - urinalysis" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="2" />
<careTeamSequence value="4" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="81003" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1D" />
<display value="Lab tests - blood counts" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="3" />
<careTeamSequence value="5" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="85027" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1H" />
<display value="Lab tests - other (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="4" />
<careTeamSequence value="6" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="80061" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1H" />
<display value="Lab tests - other (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="5" />
<careTeamSequence value="7" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="84443" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="T1A" />
<display value="Lab tests - routine venipuncture (non-Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="1" />
<display value="Service Not Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="6" />
<careTeamSequence value="8" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="5" />
<display value="Diagnostic laboratory" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="G0001" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-10-01" />
<end value="2000-10-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="1" />
<display value="100%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="60.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="200.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="60.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10659692428" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10659692428" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="7" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-07-21" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="4556" />
<display value="HEMORRHOIDS NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1B" />
<display value="Office visits - established" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99213" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-07-01" />
<end value="2000-07-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="40.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="60.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="60.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="40.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10663528372" />
<meta>
<lastUpdated value="2021-06-08T01:51:33.359+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="N" />
<display value="Non-assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10663528372" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="2000-01-01" />
<end value="2000-01-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="6" />
<display value="Assignment not accepted and all covered and allowed expenses applied to deductible non- participating." />
</valueCoding>
</extension>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="6" />
<display value="Assignment not accepted and all covered and allowed expenses applied to deductible non- participating." />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-02-25" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="70211" />
<display value="INFLAMED SBRHEIC KERATOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="P5A" />
<display value="Ambulatory procedures - skin" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="2" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="2" />
<display value="Surgery" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="17000" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-01-01" />
<end value="2000-01-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="4" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="P5A" />
<display value="Ambulatory procedures - skin" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="2" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="2" />
<display value="Surgery" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="17003" />
</coding>
</productOrService>
<servicedPeriod>
<start value="2000-01-01" />
<end value="2000-01-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="4" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="50.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="90.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="90.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="90.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10831152533" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10831152533" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-12-01" />
<end value="1999-12-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-02-04" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="78650" />
<display value="CHEST PAIN NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="78702" />
<display value="NAUSEA ALONE" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="3" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="4019" />
<display value="HYPERTENSION NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="4" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="71690" />
<display value="ARTHROPATHY NOS-UNSPEC" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="5" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M3" />
<display value="Emergency room visit" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="5" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99284" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-12-01" />
<end value="1999-12-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="200.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="200.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="70.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="200.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="90.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10833627299" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10833627299" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-12-01" />
<end value="1999-12-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-02-18" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="2222" />
<display value="BENIGN NEOPLASM PROSTATE" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M6" />
<display value="Consultations" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="3" />
<display value="Consultation" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99243" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-12-01" />
<end value="1999-12-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="100.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="100.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="80.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="80.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="100.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="100.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10841743921" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10841743921" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="1999-07-09" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="71942" />
<display value="JOINT PAIN-UP/ARM" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="I1B" />
<display value="Standard imaging - musculoskeletal" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="4" />
<display value="Diagnostic radiology" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="73080" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="9" />
<code value="99999" />
</coding>
</modifier>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="9" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="10.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="30.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="10.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10865946953" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="0" />
<display value="Denied" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10865946953" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="1999-08-06" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="72633" />
<display value="OLECRANON BURSITIS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="P6C" />
<display value="Minor procedures - other (Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="C" />
<display value="Non-covered care" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="90782" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="9" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="20.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10866191216" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="0" />
<display value="Denied" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10866191216" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="1999-11-26" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="72633" />
<display value="OLECRANON BURSITIS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="P6C" />
<display value="Minor procedures - other (Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="C" />
<display value="Non-covered care" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="90782" />
</coding>
</productOrService>
<modifier>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<version value="9" />
<code value="99999" />
</coding>
</modifier>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="20.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10875332991" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="5" />
<display value="Replacement debit" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10875332991" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<referral>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</referral>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="1" />
<display value="Participating" />
</valueCoding>
</extension>
<sequence value="3" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="3" />
<display value="Assignment accepted/non-participating" />
</valueCoding>
</extension>
<sequence value="4" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="2000-01-14" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="72633" />
<display value="OLECRANON BURSITIS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M1A" />
<display value="Office visits - new" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="99204" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="90.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="90.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="150.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="150.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="P6C" />
<display value="Minor procedures - other (Medicare fee schedule)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="C" />
<display value="Non-covered care" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="2" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="90782" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="O1E" />
<display value="Other drugs" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="O" />
<display value="Other" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="3" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="J2000" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="20.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="O1E" />
<display value="Other drugs" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="4" />
<careTeamSequence value="4" />
<diagnosisSequence value="2" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="J0702" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-06-01" />
<end value="1999-06-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="90.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="90.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="200.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="100.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="carrier--10967034142" />
<meta>
<lastUpdated value="2021-06-08T01:51:19.106+00:00" />
<profile value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician" />
</meta>
<extension url="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd" />
<code value="O" />
<display value="Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_num" />
<value value="99999" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num">
<valueIdentifier>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_cntl_num" />
<value value="00000000000000000000000" />
</valueIdentifier>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd" />
<code value="1" />
<display value="Physician/supplier" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/asgmntcd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/asgmntcd" />
<code value="A" />
<display value="Assigned claim" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_clm_entry_cd" />
<code value="1" />
<display value="Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)" />
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/variables/clm_id" />
<value value="-10967034142" />
</identifier>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="uc" />
<display value="Unique Claim ID" />
</coding>
</type>
<system value="https://bluebutton.cms.gov/resources/identifier/claim-group" />
<value value="-23945678595" />
</identifier>
<status value="active" />
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd" />
<code value="71" />
<display value="Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/eob-type" />
<code value="CARRIER" />
</coding>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type" />
<code value="professional" />
<display value="Professional" />
</coding>
</type>
<use value="claim" />
<patient>
<reference value="Patient/-19990000002208" />
</patient>
<billablePeriod>
<start value="1999-04-01" />
<end value="1999-04-01" />
</billablePeriod>
<created value="2021-08-04T03:42:24+00:00" />
<insurer>
<identifier>
<value value="CMS" />
</identifier>
</insurer>
<outcome value="complete" />
<disposition value="01" />
<careTeam>
<sequence value="1" />
<provider>
<identifier>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" />
<code value="npi" />
<display value="National Provider Identifier" />
</coding>
</type>
<value value="99999999999999" />
</identifier>
</provider>
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="referring" />
<display value="Referring" />
</coding>
</role>
</careTeam>
<careTeam>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd" />
<code value="1" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd" />
<code value="2" />
<display value="All or some covered and allowed expenses applied to deductible Participating" />
</valueCoding>
</extension>
<sequence value="2" />
<provider>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203" />
<code value="UPIN" />
<display value="Medicare/CMS (formerly HCFA)'s Universal Physician Identification numbers" />
</coding>
</type>
<value value="999999999999" />
</identifier>
</provider>
<responsible value="true" />
<role>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" />
<code value="performing" />
<display value="Performing provider" />
</coding>
</role>
<qualification>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_spclty" />
<code value="999" />
</coding>
</qualification>
</careTeam>
<supportingInfo>
<sequence value="1" />
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" />
<code value="clmrecvddate" />
<display value="Claim Received Date" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/information" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_wkly_proc_dt" />
<display value="NCH Weekly Claim Processing Date" />
</coding>
</category>
<timingDate value="1999-04-23" />
</supportingInfo>
<diagnosis>
<sequence value="1" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="36616" />
<display value="SENILE NUCLEAR CATARACT" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype" />
<code value="principal" />
<display value="principal" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="2" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="36653" />
<display value="AFTR-CATAR OBSCUR VISION" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="3" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="36250" />
<display value="MACULAR DEGENERATION NOS" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value="4" />
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-9-cm" />
<code value="9999999" />
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" />
<code value="secondary" />
<display value="Secondary" />
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value="Coverage/part-b--19990000002208" />
</coverage>
</insurance>
<item>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueQuantity>
<value value="1" />
</valueQuantity>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt" />
<code value="3" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/betos_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/betos_cd" />
<code value="M5C" />
<display value="Specialist - ophthalmology" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd" />
<code value="A" />
<display value="Allowed" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/line_service_deductible">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_service_deductible" />
<code value="0" />
<display value="Service Subject to Deductible" />
</valueCoding>
</extension>
<sequence value="1" />
<careTeamSequence value="2" />
<diagnosisSequence value="4" />
<category>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd" />
<code value="1" />
<display value="Medical care" />
</coding>
</category>
<productOrService>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/hcpcs" />
<code value="92014" />
</coding>
</productOrService>
<servicedPeriod>
<start value="1999-04-01" />
<end value="1999-04-01" />
</servicedPeriod>
<locationCodeableConcept>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_state_cd" />
<code value="99" />
<display value="With 000 county code is American Samoa; otherwise unknown" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/prvdr_zip">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/prvdr_zip" />
<code value="999999999" />
</valueCoding>
</extension>
<extension url="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd" />
<code value="99" />
</valueCoding>
</extension>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd" />
<code value="99" />
<display value="Other Place of Service. Other place of service not identified above." />
</coding>
</locationCodeableConcept>
<quantity>
<value value="1" />
</quantity>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" />
<code value="denialreason" />
<display value="Denial Reason" />
</coding>
</category>
<reason>
<coding>
<system value="https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c" />
<code value="0" />
<display value="N/A" />
</coding>
</reason>
</adjudication>
<adjudication>
<extension url="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd">
<valueCoding>
<system value="https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd" />
<code value="0" />
<display value="80%" />
</valueCoding>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="benefit" />
<display value="Benefit Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt" />
<display value="Line NCH Medicare Payment Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtopatient" />
<display value="Paid to patient" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt" />
<display value="Line Payment Amount to Beneficiary" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="paidtoprovider" />
<display value="Paid to provider" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt" />
<display value="Line Provider Payment Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="deductible" />
<display value="Deductible" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt" />
<display value="Line Beneficiary Part B Deductible Amount" />
</coding>
</category>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt" />
<display value="Line Primary Payer (if not Medicare) Paid Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="coinsurance" />
<display value="Co-insurance" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt" />
<display value="Line Beneficiary Coinsurance Amount" />
</coding>
</category>
<amount>
<value value="10.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="submitted" />
<display value="Submitted Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt" />
<display value="Line Submitted Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication" />
<code value="eligible" />
<display value="Eligible Amount" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt" />
<display value="Line Allowed Charge Amount" />
</coding>
</category>
<amount>
<value value="70.00" />
<currency value="USD" />
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" />
<code value="priorpayerpaid" />
<display value="Prior payer paid" />
</coding>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/adjudication" />
<code value="https://bluebutton.cms.gov/resources/variables/clm_tot_chrg_amt" />
<display value="Claim Total Charge Amount" />
</coding>
</category>
<amount>
<value value="0.00" />
<currency value="USD" />
</amount>
</total>
<payment>
<amount>
<value value="30.00" />
<currency value="USD" />
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/ex-benefitcategory" />
<code value="1" />
<display value="Medical Care" />
</coding>
</category>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt" />
<display value="Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)" />
</coding>
</type>
<usedMoney>
<value value="30.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt" />
<display value="NCH Claim Provider Payment Amount" />
</coding>
</type>
<usedMoney>
<value value="30.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt" />
<display value="NCH Claim Payment Amount to Beneficiary" />
</coding>
</type>
<usedMoney>
<value value="0.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt" />
<display value="NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)" />
</coding>
</type>
<usedMoney>
<value value="70.00" />
<currency value="USD" />
</usedMoney>
</financial>
<financial>
<type>
<coding>
<system value="https://bluebutton.cms.gov/resources/codesystem/benefit-balance" />
<code value="https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt" />
<display value="NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)" />
</coding>
</type>
<usedMoney>
<value value="60.00" />
<currency value="USD" />
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
</Bundle>