src/main/resources/bb-test-data/eob/-20000000001809.xml
<Bundle xmlns='http://hl7.org/fhir'>
<id value='ff6c6a4d-02c9-4503-8905-a751ad4bcdb7'/>
<meta>
<lastUpdated value='2020-09-17T17:53:11.476+00:00'/>
</meta>
<type value='searchset'/>
<total value='10'/>
<link>
<relation value='first'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=10&patient=-20000000001809'/>
</link>
<link>
<relation value='previous'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=10&patient=-20000000001809'/>
</link>
<link>
<relation value='last'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=10&patient=-20000000001809'/>
</link>
<link>
<relation value='self'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=10&_format=application%2Fjson%2Bfhir&patient=-20000000001809&startIndex=0'/>
</link>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10699300734'/>
<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='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='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='-10699300734'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-01-01'/>
<end value='2000-01-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='2724'/>
<display value='HYPERLIPIDEMIA NEC/NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='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--20000000001809'/>
</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='9'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-01-01'/>
<end value='2000-01-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='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='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>
<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--10700494443'/>
<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='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='-10700494443'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72252'/>
<display value='LUMB/LUMBOSAC DISC DEGEN'/>
</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--20000000001809'/>
</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='0'/>
<code value='72100'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</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='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='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--10700620722'/>
<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='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='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='-10700620722'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</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='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--20000000001809'/>
</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='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='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='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='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='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--10700843888'/>
<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='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='-10700843888'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7243'/>
<display value='SCIATICA'/>
</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--20000000001809'/>
</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='99212'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</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='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='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--10701442088'/>
<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='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='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='-10701442088'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</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='4280'/>
<display value='CHF 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='41400'/>
<display value='COR ATH UNSP VSL NTV/GFT'/>
</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--20000000001809'/>
</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='0'/>
<code value='99214'/>
</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='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='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='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='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_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='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='2'/>
<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='0'/>
<code value='G0001'/>
</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='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>
<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--10702253245'/>
<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='0'/>
<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='-10702253245'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-11-01'/>
<end value='2000-11-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='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='53081'/>
<display value='ESOPHAGEAL REFLUX'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7242'/>
<display value='LUMBAGO'/>
</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--20000000001809'/>
</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='T1C'/>
<display value='Lab tests - urinalysis'/>
</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='0'/>
<code value='81000'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-11-01'/>
<end value='2000-11-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='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='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='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--10702746076'/>
<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='0'/>
<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='-10702746076'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-02-01'/>
<end value='2000-02-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<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>
<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--20000000001809'/>
</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='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='0'/>
<code value='G0001'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2000-02-01'/>
<end value='2000-02-01'/>
</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='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='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--10703291318'/>
<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='-10703291318'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-04-01'/>
<end value='2000-04-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72610'/>
<display value='ROTATOR CUFF SYND 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--20000000001809'/>
</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='99212'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-04-01'/>
<end value='2000-04-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='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--10703300182'/>
<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='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='-10703300182'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-07-01'/>
<end value='2000-07-01'/>
</billablePeriod>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='2459425221'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='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--20000000001809'/>
</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='0'/>
<code value='99213'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2000-11-01'/>
<end value='2000-11-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='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='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='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--10703499424'/>
<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='60'/>
<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='10'/>
<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='-10703499424'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='48385020042'/>
</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/-20000000001809'/>
</patient>
<billablePeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='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--20000000001809'/>
</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='0'/>
<code value='99214'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</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='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_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='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_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='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_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='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='2'/>
<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='0'/>
<code value='G0001'/>
</coding>
</service>
<servicedPeriod>
<start value='2000-05-01'/>
<end value='2000-05-01'/>
</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='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='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='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
</Bundle>