src/main/resources/bb-test-data/eob/-10000010288391.json
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},
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},
{
"category": {
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},
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}
},
{
"category": {
"coding": [
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
},
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"system": "urn:iso:std:iso:4217",
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}
},
{
"category": {
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},
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}
},
{
"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
},
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"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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"display": "Allowed"
}
]
}
}
]
},
{
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt",
"valueQuantity": {
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},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd",
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"system": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_hct_hgb_rslt_num",
"valueReference": {
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}
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"diagnosisLinkId": [
1
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{
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{
"system": "https://bluebutton.cms.gov/resources/codesystem/hcpcs",
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"code": "99495"
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"url": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
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},
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
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{
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}
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]
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}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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}
]
},
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"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt",
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]
},
"amount": {
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"system": "urn:iso:std:iso:4217",
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}
},
{
"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
},
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}
},
{
"category": {
"coding": [
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]
},
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"system": "urn:iso:std:iso:4217",
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}
},
{
"category": {
"coding": [
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
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}
},
{
"category": {
"coding": [
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{
"category": {
"coding": [
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]
},
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}
},
{
"category": {
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]
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},
{
"category": {
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]
},
"reason": {
"coding": [
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]
}
}
]
},
{
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{
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}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd",
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},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_hct_hgb_rslt_num",
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}
}
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},
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"url": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
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},
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
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},
{
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}
],
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"category": {
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]
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}
},
{
"category": {
"coding": [
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]
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},
{
"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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}
]
},
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"system": "urn:iso:std:iso:4217",
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},
{
"category": {
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]
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{
"category": {
"coding": [
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
},
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},
{
"category": {
"coding": [
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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}
},
{
"category": {
"coding": [
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{
"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
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},
{
"category": {
"coding": [
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]
},
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},
{
"category": {
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]
},
"reason": {
"coding": [
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"system": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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]
}
}
]
},
{
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},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd",
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}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_hct_hgb_rslt_num",
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}
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]
},
"servicedPeriod": {
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"extension": [
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"url": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
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}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
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},
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
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}
],
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
},
"reason": {
"coding": [
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]
}
},
{
"category": {
"coding": [
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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]
},
"amount": {
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"system": "urn:iso:std:iso:4217",
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}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt",
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}
]
},
"amount": {
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"system": "urn:iso:std:iso:4217",
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},
{
"category": {
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]
},
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},
{
"category": {
"coding": [
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]
},
"amount": {
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},
{
"category": {
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}
},
{
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}
}
]
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},
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{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"code": "9",
"display": "REST OF CALIFORNIA"
}
}
],
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd",
"code": "11",
"display": "Office. Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis."
}
]
},
"quantity": {
"value": 8
},
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{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"display": "Carrier Line Reduced Payment Physician Assistant Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"code": "0",
"display": "N/A"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt",
"display": "Line NCH Medicare Payment Amount"
}
]
},
"amount": {
"value": 480.40,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt",
"display": "Line Payment Amount to Beneficiary"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
"display": "Line Provider Payment Amount"
}
]
},
"amount": {
"value": 480.40,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
"display": "Line Beneficiary Part B Deductible Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt",
"display": "Line Primary Payer (if not Medicare) Paid Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
"display": "Line Beneficiary Coinsurance Amount"
}
]
},
"amount": {
"value": 480.40,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
"display": "Line Submitted Charge Amount"
}
]
},
"amount": {
"value": 600.50,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
"display": "Line Allowed Charge Amount"
}
]
},
"amount": {
"value": 600.50,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"display": "Line Processing Indicator Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"code": "A",
"display": "Allowed"
}
]
}
}
]
},
{
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt",
"valueQuantity": {
"value": 39
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_hct_hgb_rslt_num",
"valueReference": {
"reference": "#8"
}
}
],
"sequence": 7,
"careTeamLinkId": [
2
],
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code": "1",
"display": "Medical care"
}
]
},
"servicedPeriod": {
"start": "2016-11-26",
"end": "2016-11-26"
},
"locationCodeableConcept": {
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
"code": "CA"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
"code": "925631405"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"code": "9",
"display": "REST OF CALIFORNIA"
}
}
],
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd",
"code": "11",
"display": "Office. Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis."
}
]
},
"quantity": {
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"adjudication": [
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"display": "Carrier Line Reduced Payment Physician Assistant Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"code": "0",
"display": "N/A"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt",
"display": "Line NCH Medicare Payment Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt",
"display": "Line Payment Amount to Beneficiary"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
"display": "Line Provider Payment Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
"display": "Line Beneficiary Part B Deductible Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt",
"display": "Line Primary Payer (if not Medicare) Paid Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
"display": "Line Beneficiary Coinsurance Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
"display": "Line Submitted Charge Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
"display": "Line Allowed Charge Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"display": "Line Processing Indicator Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"code": "A",
"display": "Allowed"
}
]
}
}
]
},
{
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt",
"valueQuantity": {
"value": 39
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_hct_hgb_rslt_num",
"valueReference": {
"reference": "#9"
}
}
],
"sequence": 8,
"careTeamLinkId": [
2
],
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code": "1",
"display": "Medical care"
}
]
},
"service": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/hcpcs",
"version": "1",
"code": "99401"
}
]
},
"servicedPeriod": {
"start": "2016-11-26",
"end": "2016-11-26"
},
"locationCodeableConcept": {
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
"code": "CA"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
"code": "925631405"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"code": "9",
"display": "REST OF CALIFORNIA"
}
}
],
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd",
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"display": "Office. Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis."
}
]
},
"quantity": {
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"adjudication": [
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"display": "Carrier Line Reduced Payment Physician Assistant Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
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"display": "N/A"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt",
"display": "Line NCH Medicare Payment Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt",
"display": "Line Payment Amount to Beneficiary"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
"display": "Line Provider Payment Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
"display": "Line Beneficiary Part B Deductible Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt",
"display": "Line Primary Payer (if not Medicare) Paid Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
"display": "Line Beneficiary Coinsurance Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
"display": "Line Submitted Charge Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
"display": "Line Allowed Charge Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"display": "Line Processing Indicator Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"code": "A",
"display": "Allowed"
}
]
}
}
]
},
{
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt",
"valueQuantity": {
"value": 39
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_cd"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/line_hct_hgb_rslt_num",
"valueReference": {
"reference": "#10"
}
}
],
"sequence": 9,
"careTeamLinkId": [
2
],
"diagnosisLinkId": [
1
],
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
"code": "1",
"display": "Medical care"
}
]
},
"servicedPeriod": {
"start": "2016-11-26",
"end": "2016-11-26"
},
"locationCodeableConcept": {
"extension": [
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/prvdr_state_cd",
"code": "CA"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/prvdr_zip",
"code": "925631405"
}
},
{
"url": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"valueCoding": {
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd",
"code": "9",
"display": "REST OF CALIFORNIA"
}
}
],
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd",
"code": "11",
"display": "Office. Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis."
}
]
},
"quantity": {
"value": 8
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"adjudication": [
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"display": "Carrier Line Reduced Payment Physician Assistant Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c",
"code": "0",
"display": "N/A"
}
]
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt",
"display": "Line NCH Medicare Payment Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt",
"display": "Line Payment Amount to Beneficiary"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
"display": "Line Provider Payment Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
"display": "Line Beneficiary Part B Deductible Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt",
"display": "Line Primary Payer (if not Medicare) Paid Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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]
},
"amount": {
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"system": "urn:iso:std:iso:4217",
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}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
"display": "Line Submitted Charge Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
"display": "Line Allowed Charge Amount"
}
]
},
"amount": {
"value": 0.00,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
},
{
"category": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"display": "Line Processing Indicator Code"
}
]
},
"reason": {
"coding": [
{
"system": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
"code": "A",
"display": "Allowed"
}
]
}
}
]
}
],
"payment": {
"amount": {
"value": 1484.87,
"system": "urn:iso:std:iso:4217",
"code": "USD"
}
}
}
}
]
}