src/main/resources/bb-test-data-v2/eob/-19990000002210_20.xml
<Bundle xmlns='http://hl7.org/fhir'>
<id value='55b2815f-4210-4853-b3a6-b63d8f0a0bbd'/>
<meta>
<lastUpdated value='2020-04-24T18:46:46.726+00:00'/>
</meta>
<type value='searchset'/>
<total value='68'/>
<link>
<relation value='first'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='next'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=40&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='previous'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='last'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=60&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='self'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=20&_format=application%2Fjson%2Bfhir&patient=-19990000002210&startIndex=20'/>
</link>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10558914960'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-10558914960'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2000-08-01'/>
<end value='2000-08-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='2720'/>
<display value='PURE HYPERCHOLESTEROLEM'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='25000'/>
<display value='DMII WO CMP NT ST UNCNTR'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='80061'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10560795673'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-10560795673'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2000-07-01'/>
<end value='2000-07-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='5289'/>
<display value='ORAL SOFT TISSUE DIS NEC'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='2724'/>
<display value='HYPERLIPIDEMIA NEC/NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99212'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='3'/>
<display value='85% of payment. Either physician assistant services for other than assisting surgery or other hospital services or nurse practitioners services (not in rural areas)'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10564034813'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-10564034813'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2000-08-01'/>
<end value='2000-08-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71945'/>
<display value='JOINT PAIN-PELVIS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='72100'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10581649843'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-10581649843'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2000-08-01'/>
<end value='2000-08-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</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>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71500'/>
<display value='GENERAL OSTEOARTHROSIS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='G0001'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='85022'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='80053'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='80061'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='84450'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='O'/>
<display value='Other'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='84550'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10666095040'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-10666095040'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2000-12-01'/>
<end value='2000-12-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='37991'/>
<display value='PAIN IN OR AROUND EYE'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='37515'/>
<display value='TEAR FILM INSUFFIC NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='36616'/>
<display value='SENILE NUCLEAR CATARACT'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='3670'/>
<display value='HYPERMETROPIA'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='5'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-12-01'/>
<end value='2000-12-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='5'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92015'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-12-01'/>
<end value='2000-12-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11079420166'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='450'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11079420166'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-06-01'/>
<end value='1999-06-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71946'/>
<display value='JOINT PAIN-L/LEG'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I2D'/>
<display value='Advanced imaging - MRI/MRA: 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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='73721'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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='90'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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='450'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11083624281'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11083624281'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-06-01'/>
<end value='1999-06-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7179'/>
<display value='INT DERANGEMENT KNEE NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99213'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11096633494'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11096633494'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-06-01'/>
<end value='1999-06-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7179'/>
<display value='INT DERANGEMENT KNEE NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99214'/>
</coding>
</service>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11269359497'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11269359497'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-04-01'/>
<end value='1999-04-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='6119'/>
<display value='BREAST DISORDER NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I1C'/>
<display value='Standard imaging - breast'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='76091'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11292205268'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11292205268'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='6111'/>
<display value='HYPERTROPHY OF BREAST'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7231'/>
<display value='CERVICALGIA'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71941'/>
<display value='JOINT PAIN-SHLDER'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='61171'/>
<display value='MASTODYNIA'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='5'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11377169356'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11377169356'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-11-01'/>
<end value='1999-11-01'/>
</billablePeriod>
<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='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='92014'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-11-01'/>
<end value='1999-11-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11377614619'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11377614619'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-12-01'/>
<end value='1999-12-01'/>
</billablePeriod>
<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='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='92004'/>
</coding>
</service>
<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='1999-12-01'/>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I3A'/>
<display value='Echography/ultrasonography - eye'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='76519'/>
</coding>
</service>
<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='1999-12-01'/>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I3A'/>
<display value='Echography/ultrasonography - eye'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='76519'/>
</coding>
</service>
<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='1999-12-01'/>
<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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11384998515'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11384998515'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71590'/>
<display value='OSTEOARTHROS NOS-UNSPEC'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7245'/>
<display value='BACKACHE NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99213'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11385105874'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11385105874'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-01-01'/>
<end value='1999-01-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71590'/>
<display value='OSTEOARTHROS NOS-UNSPEC'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='8'/>
<code value='99212'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='8'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-01-01'/>
<end value='1999-01-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11385746835'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-11385746835'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7245'/>
<display value='BACKACHE NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='71598'/>
<display value='OSTEOARTHRO NOS-OTH SITE'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99213'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='72100'/>
</coding>
</service>
<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='1999-05-01'/>
<end value='1999-05-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='72100'/>
</coding>
</service>
<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='1999-05-01'/>
<end value='1999-05-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9644745533'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9644745533'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2001-04-01'/>
<end value='2001-04-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='2720'/>
<display value='PURE HYPERCHOLESTEROLEM'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='80053'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-04-01'/>
<end value='2001-04-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='80061'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-04-01'/>
<end value='2001-04-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9763943571'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9763943571'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2001-03-01'/>
<end value='2001-03-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4619'/>
<display value='ACUTE SINUSITIS NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-03-01'/>
<end value='2001-03-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9919435419'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='90'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9919435419'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2001-11-01'/>
<end value='2001-11-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='6929'/>
<display value='DERMATITIS NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/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_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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-11-01'/>
<end value='2001-11-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='3'/>
<display value='85% of payment. Either physician assistant services for other than assisting surgery or other hospital services or nurse practitioners services (not in rural areas)'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='Y1'/>
<display value='Other - Medicare fee schedule'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99050'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-11-01'/>
<end value='2001-11-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9921223338'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9921223338'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4240'/>
<display value='MITRAL VALVE DISORDER'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I3C'/>
<display value='Echography/ultrasonography - heart'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93307'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='R'/>
<display value='Reprocessed--adjustments based on subsequent reprocessing of claim'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I3C'/>
<display value='Echography/ultrasonography - heart'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93320'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='R'/>
<display value='Reprocessed--adjustments based on subsequent reprocessing of claim'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I3C'/>
<display value='Echography/ultrasonography - heart'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93325'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='R'/>
<display value='Reprocessed--adjustments based on subsequent reprocessing of claim'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9922872715'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</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_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_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9922872715'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</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://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<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)'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7859'/>
<display value='CARDIOVAS SYS SYMP NEC'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<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/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I3D'/>
<display value='Echography/ultrasonography - carotid arteries'/>
</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'/>
<diagnosisLinkId 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>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93880'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</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='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</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='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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<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'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
</Bundle>