35695 lines
1.1 MiB
35695 lines
1.1 MiB
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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"currency": "USD"
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}
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}, {
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Beneficiary Part B Deductible Amount"
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} ]
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},
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"amount": {
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"value": 0,
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"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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}, {
|
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"sequence": 3,
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"diagnosisSequence": [ 1 ],
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
|
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"display": "Medical care"
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} ]
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},
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"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "314529007",
|
|
"display": "Medication review due (situation)"
|
|
} ],
|
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"text": "Medication review due (situation)"
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},
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|
"servicedPeriod": {
|
|
"start": "2014-01-10T21:33:10+01:00",
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"end": "2014-01-10T21:48:10+01:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
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"display": "Off Campus-Outpatient Hospital"
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} ]
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}
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}, {
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"sequence": 4,
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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"display": "Medical care"
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} ]
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},
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"productOrService": {
|
|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
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|
},
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"servicedPeriod": {
|
|
"start": "2014-01-10T21:33:10+01:00",
|
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"end": "2014-01-10T21:48:10+01:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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"display": "Off Campus-Outpatient Hospital"
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|
} ]
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},
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"net": {
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"value": 396.45,
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"currency": "USD"
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},
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"adjudication": [ {
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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} ]
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},
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"amount": {
|
|
"value": 79.29,
|
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"currency": "USD"
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}
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}, {
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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"display": "Line Provider Payment Amount"
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} ]
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},
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"amount": {
|
|
"value": 317.16,
|
|
"currency": "USD"
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}
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}, {
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"amount": {
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"value": 396.45,
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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} ]
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},
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"amount": {
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"value": 396.45,
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"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Beneficiary Part B Deductible Amount"
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} ]
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},
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"amount": {
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"value": 0,
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"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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}, {
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"sequence": 5,
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"informationSequence": [ 2 ],
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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|
"display": "Medical care"
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} ]
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},
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"productOrService": {
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"coding": [ {
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"system": "http://loinc.org",
|
|
"code": "58410-2",
|
|
"display": "CBC panel - Blood by Automated count"
|
|
} ],
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"text": "CBC panel - Blood by Automated count"
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},
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"servicedPeriod": {
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|
"start": "2014-01-10T21:33:10+01:00",
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"end": "2014-01-10T21:48:10+01:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
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} ]
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},
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"value": 74.58,
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},
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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} ]
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},
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"amount": {
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"value": 14.916,
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}
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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"display": "Line Provider Payment Amount"
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} ]
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},
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"amount": {
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"value": 59.664,
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"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"value": 74.58,
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}
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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} ]
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},
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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} ]
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},
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"amount": {
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"value": 0,
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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} ],
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"total": [ {
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"category": {
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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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|
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|
"display": "Submitted Amount"
|
|
} ],
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"text": "Submitted Amount"
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},
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"value": 743.83,
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}
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} ],
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"payment": {
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}
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}
|
|
},
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|
"request": {
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|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
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|
}
|
|
}, {
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|
"fullUrl": "urn:uuid:b62a8951-86ff-c9d1-99bd-3562067a87f5",
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"resource": {
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"resourceType": "Encounter",
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"id": "b62a8951-86ff-c9d1-99bd-3562067a87f5",
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
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},
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"identifier": [ {
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|
"use": "official",
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"system": "https://github.com/synthetichealth/synthea",
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"value": "b62a8951-86ff-c9d1-99bd-3562067a87f5"
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} ],
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"status": "finished",
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"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
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"code": "AMB"
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|
},
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|
"type": [ {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
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|
} ],
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"text": "Well child visit (procedure)"
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|
} ],
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"subject": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e",
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"display": "Donnell534 Ted955 Koss676"
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|
},
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"participant": [ {
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"type": [ {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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|
"code": "PPRF",
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|
"display": "primary performer"
|
|
} ],
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"text": "primary performer"
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} ],
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"period": {
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|
"start": "2014-02-14T21:33:10+01:00",
|
|
"end": "2014-02-14T21:48:10+01:00"
|
|
},
|
|
"individual": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094",
|
|
"display": "Dr. Ester635 Baca589"
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}
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} ],
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"period": {
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|
"start": "2014-02-14T21:33:10+01:00",
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"end": "2014-02-14T21:48:10+01:00"
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},
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"location": [ {
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"location": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
|
|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
}
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|
} ],
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"serviceProvider": {
|
|
"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|a4b91172-69e7-3895-bd89-b9a0868de5c2",
|
|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
}
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|
},
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|
"request": {
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|
"method": "POST",
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|
"url": "Encounter"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:1636332d-b9d1-4c6b-5f0e-fd8164049df1",
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"resource": {
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|
"resourceType": "Condition",
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|
"id": "1636332d-b9d1-4c6b-5f0e-fd8164049df1",
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|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis" ]
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|
},
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"clinicalStatus": {
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|
"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
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"code": "resolved"
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|
} ]
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},
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"verificationStatus": {
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|
"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
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"code": "confirmed"
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} ]
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},
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"category": [ {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/condition-category",
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|
"code": "encounter-diagnosis",
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|
"display": "Encounter Diagnosis"
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|
} ]
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|
} ],
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"code": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
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|
"code": "314529007",
|
|
"display": "Medication review due (situation)"
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|
} ],
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"text": "Medication review due (situation)"
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},
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"subject": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"abatementDateTime": "2014-02-14T21:33:10+01:00",
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|
"recordedDate": "2014-02-14T21:33:10+01:00"
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|
},
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|
"request": {
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|
"method": "POST",
|
|
"url": "Condition"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:c49c76fc-01e8-cc06-655e-647dc31f6a16",
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"resource": {
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|
"resourceType": "Observation",
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|
"id": "c49c76fc-01e8-cc06-655e-647dc31f6a16",
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|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-height" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8302-2",
|
|
"display": "Body Height"
|
|
} ],
|
|
"text": "Body Height"
|
|
},
|
|
"subject": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
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"encounter": {
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|
},
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|
"effectiveDateTime": "2014-02-14T21:33:10+01:00",
|
|
"issued": "2014-02-14T21:33:10.614+01:00",
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|
"valueQuantity": {
|
|
"value": 58.1,
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|
"unit": "cm",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "cm"
|
|
}
|
|
},
|
|
"request": {
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|
"method": "POST",
|
|
"url": "Observation"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:721048db-d168-4c92-0fab-2b60b0e88945",
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|
"resource": {
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|
"resourceType": "Observation",
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|
"id": "721048db-d168-4c92-0fab-2b60b0e88945",
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|
"status": "final",
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|
"category": [ {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
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|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72514-3",
|
|
"display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
|
|
} ],
|
|
"text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
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|
},
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"subject": {
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"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"effectiveDateTime": "2014-02-14T21:33:10+01:00",
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|
"issued": "2014-02-14T21:33:10.614+01:00",
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|
"valueQuantity": {
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|
"value": 4,
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|
"unit": "{score}",
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|
"system": "http://unitsofmeasure.org",
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|
"code": "{score}"
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|
}
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|
},
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|
"request": {
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"meta": {
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-weight" ]
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},
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"status": "final",
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"system": "http://terminology.hl7.org/CodeSystem/observation-category",
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"code": "vital-signs",
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} ],
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"coding": [ {
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"system": "http://loinc.org",
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"code": "29463-7",
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"display": "Body Weight"
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|
} ],
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"text": "Body Weight"
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},
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"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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}
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},
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/pediatric-weight-for-height" ]
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},
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} ],
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"code": "77606-2",
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} ],
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"text": "Weight-for-length Per age and sex"
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/head-occipital-frontal-circumference-percentile" ]
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},
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"code": "8289-1",
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} ],
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},
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"code": "9843-4",
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} ],
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-blood-pressure" ]
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},
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} ],
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"code": "85354-9",
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} ],
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},
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"system": "http://snomed.info/sct",
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"code": "266919005",
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"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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"resourceType": "Immunization",
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},
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"status": "completed",
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"vaccineCode": {
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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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"code": "08",
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} ],
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"request": {
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},
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"coding": [ {
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"system": "http://loinc.org",
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"code": "34117-2",
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"display": "History and physical note"
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}, {
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|
"system": "http://loinc.org",
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|
"code": "51847-2",
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"display": "Evaluation + Plan note"
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} ],
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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"display": "Line Provider Payment Amount"
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} ]
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},
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"value": 108.80000000000001,
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}
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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}
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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}
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Beneficiary Part B Deductible Amount"
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} ]
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},
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"amount": {
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"value": 0,
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"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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}, {
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"sequence": 3,
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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"display": "Medical care"
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} ]
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},
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"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
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|
"code": "314529007",
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} ],
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},
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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} ]
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}
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}, {
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} ]
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},
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"code": "430193006",
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"display": "Medication Reconciliation (procedure)"
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} ],
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"text": "Medication Reconciliation (procedure)"
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},
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"servicedPeriod": {
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"start": "2014-02-14T21:33:10+01:00",
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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} ]
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},
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"value": 372.97,
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},
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"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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} ]
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},
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"amount": {
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"value": 74.59400000000001,
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} ]
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} ],
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}
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},
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"request": {
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:e22ef8a9-52b2-c2fa-16ad-99de17a4ce3b",
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"resource": {
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},
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},
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"individual": {
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} ],
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"serviceProvider": {
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"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
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},
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|
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|
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|
"display": "Vital signs"
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|
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|
} ],
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|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8302-2",
|
|
"display": "Body Height"
|
|
} ],
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|
"text": "Body Height"
|
|
},
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|
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|
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|
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|
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|
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|
|
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|
} ],
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|
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|
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|
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|
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|
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|
},
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|
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|
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|
"code": "vital-signs",
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|
"display": "Vital signs"
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|
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} ],
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"code": {
|
|
"coding": [ {
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|
"system": "http://loinc.org",
|
|
"code": "29463-7",
|
|
"display": "Body Weight"
|
|
} ],
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|
"text": "Body Weight"
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|
},
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|
"subject": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
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|
"valueQuantity": {
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|
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|
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|
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|
|
"code": "kg"
|
|
}
|
|
},
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|
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|
"method": "POST",
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|
"url": "Observation"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:44d9bc28-362d-1970-0234-8108c406675e",
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|
"id": "44d9bc28-362d-1970-0234-8108c406675e",
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|
"meta": {
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|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/pediatric-weight-for-height" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
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|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "77606-2",
|
|
"display": "Weight-for-length Per age and sex"
|
|
} ],
|
|
"text": "Weight-for-length Per age and sex"
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|
},
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|
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|
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"code": "%"
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}
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},
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},
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"code": "8289-1",
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} ],
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"text": "Head Occipital-frontal circumference Percentile"
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},
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} ],
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},
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|
|
"resourceType": "ServiceRequest",
|
|
"id": "referral",
|
|
"status": "completed",
|
|
"intent": "order",
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
|
|
"requester": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
},
|
|
"performer": [ {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
} ]
|
|
}, {
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Anthem"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
|
|
},
|
|
"payor": [ {
|
|
"display": "Anthem"
|
|
} ]
|
|
} ],
|
|
"identifier": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "1c2fbb2a-87f0-117b-7727-b64ce98cea03"
|
|
}, {
|
|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
|
|
"value": "99999999999"
|
|
} ],
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "professional"
|
|
} ]
|
|
},
|
|
"use": "claim",
|
|
"patient": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "2014-04-18T22:48:10+02:00",
|
|
"end": "2015-04-18T22:48:10+02:00"
|
|
},
|
|
"created": "2014-04-18T22:48:10+02:00",
|
|
"insurer": {
|
|
"display": "Anthem"
|
|
},
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"facility": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
|
|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:1c2fbb2a-87f0-117b-7727-b64ce98cea03"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [ {
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
},
|
|
"role": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary provider"
|
|
} ]
|
|
}
|
|
} ],
|
|
"diagnosis": [ {
|
|
"sequence": 1,
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|
"diagnosisReference": {
|
|
"reference": "urn:uuid:b6b2cc04-80cb-a8a4-4ef4-e89c9807b2a1"
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|
},
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|
"type": [ {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
|
|
"code": "principal"
|
|
} ]
|
|
} ]
|
|
} ],
|
|
"insurance": [ {
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Anthem"
|
|
}
|
|
} ],
|
|
"item": [ {
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|
"sequence": 1,
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
|
|
"text": "Well child visit (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-04-18T22:33:10+02:00",
|
|
"end": "2014-04-18T22:48:10+02:00"
|
|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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|
},
|
|
"encounter": [ {
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|
"reference": "urn:uuid:e22ef8a9-52b2-c2fa-16ad-99de17a4ce3b"
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|
} ]
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|
}, {
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|
"sequence": 2,
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"informationSequence": [ 1 ],
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
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|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "49",
|
|
"display": "Hib (PRP-OMP)"
|
|
} ],
|
|
"text": "Hib (PRP-OMP)"
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|
},
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|
"servicedPeriod": {
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|
"start": "2014-04-18T22:33:10+02:00",
|
|
"end": "2014-04-18T22:48:10+02:00"
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|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
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|
},
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|
"adjudication": [ {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
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|
} ]
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|
},
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|
"amount": {
|
|
"value": 27.200000000000003,
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|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
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},
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|
"amount": {
|
|
"value": 108.80000000000001,
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|
"currency": "USD"
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}
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|
}, {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
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|
},
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|
"amount": {
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|
"value": 136.00,
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|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
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|
},
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|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
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|
}
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|
}, {
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"category": {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
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|
}
|
|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 3,
|
|
"informationSequence": [ 2 ],
|
|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "119",
|
|
"display": "rotavirus, monovalent"
|
|
} ],
|
|
"text": "rotavirus, monovalent"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-04-18T22:33:10+02:00",
|
|
"end": "2014-04-18T22:48:10+02:00"
|
|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
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|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
|
|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 4,
|
|
"informationSequence": [ 3 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "10",
|
|
"display": "IPV"
|
|
} ],
|
|
"text": "IPV"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-04-18T22:33:10+02:00",
|
|
"end": "2014-04-18T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
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|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 5,
|
|
"informationSequence": [ 4 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "20",
|
|
"display": "DTaP"
|
|
} ],
|
|
"text": "DTaP"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-04-18T22:33:10+02:00",
|
|
"end": "2014-04-18T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
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"code": "133",
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"display": "Pneumococcal conjugate PCV 13"
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} ],
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|
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|
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|
|
"code": "8302-2",
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|
"display": "Body Height"
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|
} ],
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|
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|
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"code": "72514-3",
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|
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|
} ],
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},
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"system": "http://loinc.org",
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"code": "29463-7",
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"display": "Body Weight"
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} ],
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"sequence": 4,
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"informationSequence": [ 3 ],
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"productOrService": {
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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "10",
|
|
"display": "IPV"
|
|
} ],
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"text": "IPV"
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|
},
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"net": {
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"value": 136.00,
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"currency": "USD"
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|
}
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|
}, {
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"sequence": 5,
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"informationSequence": [ 4 ],
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"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "20",
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|
"display": "DTaP"
|
|
} ],
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"text": "DTaP"
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},
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"net": {
|
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"value": 136.00,
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"currency": "USD"
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}
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}, {
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"sequence": 6,
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"informationSequence": [ 5 ],
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"productOrService": {
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "133",
|
|
"display": "Pneumococcal conjugate PCV 13"
|
|
} ],
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"text": "Pneumococcal conjugate PCV 13"
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|
},
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"net": {
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|
"value": 136.00,
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"currency": "USD"
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}
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}, {
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"sequence": 7,
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"productOrService": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "314529007",
|
|
"display": "Medication review due (situation)"
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|
} ],
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"text": "Medication review due (situation)"
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|
}
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|
}, {
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"sequence": 8,
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"procedureSequence": [ 1 ],
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"productOrService": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
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|
} ],
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"text": "Medication Reconciliation (procedure)"
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},
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"net": {
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|
"value": 489.11,
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"currency": "USD"
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}
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|
} ],
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"total": {
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"value": 1305.91,
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"currency": "USD"
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}
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},
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"request": {
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"method": "POST",
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"url": "Claim"
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}
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}, {
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"fullUrl": "urn:uuid:7ca67a1f-ad4f-5df9-27f8-0ed99089bca4",
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"resource": {
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"resourceType": "ExplanationOfBenefit",
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"id": "7ca67a1f-ad4f-5df9-27f8-0ed99089bca4",
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"contained": [ {
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"resourceType": "ServiceRequest",
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"id": "referral",
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"status": "completed",
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"intent": "order",
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"subject": {
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"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"requester": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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},
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"performer": [ {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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} ]
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}, {
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"resourceType": "Coverage",
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"id": "coverage",
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"status": "active",
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"type": {
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"text": "Anthem"
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},
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"beneficiary": {
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"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"payor": [ {
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"display": "Anthem"
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|
} ]
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|
} ],
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"identifier": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
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"value": "4c7f6922-71ee-0568-341f-e0d73c811260"
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}, {
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"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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"value": "99999999999"
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|
} ],
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"status": "active",
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"type": {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
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"code": "professional"
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|
} ]
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},
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"use": "claim",
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"patient": {
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"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"billablePeriod": {
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"start": "2014-06-20T22:48:10+02:00",
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"end": "2015-06-20T22:48:10+02:00"
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},
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"created": "2014-06-20T22:48:10+02:00",
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"insurer": {
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|
"display": "Anthem"
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|
},
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|
"provider": {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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|
},
|
|
"referral": {
|
|
"reference": "#referral"
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|
},
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"facility": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
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|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
},
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|
"claim": {
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|
"reference": "urn:uuid:4c7f6922-71ee-0568-341f-e0d73c811260"
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|
},
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|
"outcome": "complete",
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|
"careTeam": [ {
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|
"sequence": 1,
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|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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|
},
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|
"role": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
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|
"code": "primary",
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|
"display": "Primary provider"
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} ]
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}
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|
} ],
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"diagnosis": [ {
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"sequence": 1,
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"diagnosisReference": {
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"reference": "urn:uuid:b4361fcc-3313-98f3-50b1-ea121f9a45ba"
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},
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"type": [ {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
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"code": "principal"
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|
} ]
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|
} ]
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|
} ],
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"insurance": [ {
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|
"focal": true,
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|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Anthem"
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|
}
|
|
} ],
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"item": [ {
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"sequence": 1,
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"category": {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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|
"display": "Medical care"
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|
} ]
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},
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
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|
} ],
|
|
"text": "Well child visit (procedure)"
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|
},
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"servicedPeriod": {
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|
"start": "2014-06-20T22:33:10+02:00",
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"end": "2014-06-20T22:48:10+02:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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} ]
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},
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"encounter": [ {
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|
"reference": "urn:uuid:5a6d9a68-8a4a-b46c-20a9-5b870a0d0493"
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} ]
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}, {
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"sequence": 2,
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"informationSequence": [ 1 ],
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"category": {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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|
"display": "Medical care"
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|
} ]
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|
},
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|
"productOrService": {
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "49",
|
|
"display": "Hib (PRP-OMP)"
|
|
} ],
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|
"text": "Hib (PRP-OMP)"
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},
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"servicedPeriod": {
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|
"start": "2014-06-20T22:33:10+02:00",
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"end": "2014-06-20T22:48:10+02:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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},
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"net": {
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"value": 136.00,
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"currency": "USD"
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},
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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|
"display": "Line Beneficiary Coinsurance Amount"
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|
} ]
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|
},
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|
"amount": {
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|
"value": 27.200000000000003,
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|
"currency": "USD"
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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|
"display": "Line Provider Payment Amount"
|
|
} ]
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},
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"amount": {
|
|
"value": 108.80000000000001,
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"currency": "USD"
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}
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|
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"category": {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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|
"display": "Line Submitted Charge Amount"
|
|
} ]
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|
},
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|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
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}
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|
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
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|
"amount": {
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"value": 0,
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"currency": "USD"
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
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|
}
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|
} ]
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}, {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
|
|
"display": "Medical care"
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|
} ]
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|
},
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"productOrService": {
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|
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|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "119",
|
|
"display": "rotavirus, monovalent"
|
|
} ],
|
|
"text": "rotavirus, monovalent"
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|
},
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|
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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},
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|
"value": 136.00,
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"currency": "USD"
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},
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"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
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|
"amount": {
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|
"value": 27.200000000000003,
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|
"currency": "USD"
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}
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"category": {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
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|
"currency": "USD"
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|
}
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|
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|
"category": {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
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},
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"amount": {
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|
|
"currency": "USD"
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}
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|
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|
"category": {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
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|
},
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"amount": {
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|
"value": 136.00,
|
|
"currency": "USD"
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}
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
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|
"amount": {
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|
"value": 0,
|
|
"currency": "USD"
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|
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|
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|
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|
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|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 4,
|
|
"informationSequence": [ 3 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "10",
|
|
"display": "IPV"
|
|
} ],
|
|
"text": "IPV"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-06-20T22:33:10+02:00",
|
|
"end": "2014-06-20T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
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|
"value": 27.200000000000003,
|
|
"currency": "USD"
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|
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
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|
}
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
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"value": 0,
|
|
"currency": "USD"
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}
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"code": "encounter-diagnosis",
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"display": "Encounter Diagnosis"
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},
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},
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"system": "http://terminology.hl7.org/CodeSystem/observation-category",
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"code": "vital-signs",
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|
"display": "Vital signs"
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} ]
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} ],
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
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|
"code": "info"
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|
} ]
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|
},
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|
"valueReference": {
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|
"reference": "urn:uuid:aa13d63e-6746-052d-240f-94a452981a36"
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|
}
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}, {
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"sequence": 5,
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"category": {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
|
|
"code": "info"
|
|
} ]
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|
},
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"valueReference": {
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|
"reference": "urn:uuid:7acded99-f0e6-6902-b1b9-319c5d399197"
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}
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} ],
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"diagnosis": [ {
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"sequence": 1,
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"diagnosisReference": {
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|
"reference": "urn:uuid:4fee0291-8872-f64a-16d9-c02bba20eb76"
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}
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} ],
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"procedure": [ {
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|
"sequence": 1,
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"procedureReference": {
|
|
"reference": "urn:uuid:f1a30666-4379-6fb1-101c-7fb312458eeb"
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|
}
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|
} ],
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"insurance": [ {
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|
"sequence": 1,
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|
"focal": true,
|
|
"coverage": {
|
|
"display": "Anthem"
|
|
}
|
|
} ],
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|
"item": [ {
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|
"sequence": 1,
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|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
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|
"text": "Well child visit (procedure)"
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|
},
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|
"encounter": [ {
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|
"reference": "urn:uuid:18cfb879-6c94-f4b7-18b1-f79c5104d0f5"
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|
} ]
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|
}, {
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"sequence": 2,
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"informationSequence": [ 1 ],
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|
"productOrService": {
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|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "10",
|
|
"display": "IPV"
|
|
} ],
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|
"text": "IPV"
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|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"sequence": 3,
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|
"informationSequence": [ 2 ],
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|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
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|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"sequence": 4,
|
|
"informationSequence": [ 3 ],
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|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "20",
|
|
"display": "DTaP"
|
|
} ],
|
|
"text": "DTaP"
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"sequence": 5,
|
|
"informationSequence": [ 4 ],
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|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "133",
|
|
"display": "Pneumococcal conjugate PCV 13"
|
|
} ],
|
|
"text": "Pneumococcal conjugate PCV 13"
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
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|
}, {
|
|
"sequence": 6,
|
|
"informationSequence": [ 5 ],
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|
"productOrService": {
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|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "08",
|
|
"display": "Hep B, adolescent or pediatric"
|
|
} ],
|
|
"text": "Hep B, adolescent or pediatric"
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
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|
}, {
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|
"sequence": 7,
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"diagnosisSequence": [ 1 ],
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|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "314529007",
|
|
"display": "Medication review due (situation)"
|
|
} ],
|
|
"text": "Medication review due (situation)"
|
|
}
|
|
}, {
|
|
"sequence": 8,
|
|
"procedureSequence": [ 1 ],
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"net": {
|
|
"value": 434.57,
|
|
"currency": "USD"
|
|
}
|
|
} ],
|
|
"total": {
|
|
"value": 1251.37,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Claim"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:3e97c72e-f7c1-cdad-3917-99c634291991",
|
|
"resource": {
|
|
"resourceType": "ExplanationOfBenefit",
|
|
"id": "3e97c72e-f7c1-cdad-3917-99c634291991",
|
|
"contained": [ {
|
|
"resourceType": "ServiceRequest",
|
|
"id": "referral",
|
|
"status": "completed",
|
|
"intent": "order",
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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|
"requester": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
},
|
|
"performer": [ {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
} ]
|
|
}, {
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Anthem"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
|
|
},
|
|
"payor": [ {
|
|
"display": "Anthem"
|
|
} ]
|
|
} ],
|
|
"identifier": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "f753a40e-44e9-7e21-4b8e-01ca23d5ade3"
|
|
}, {
|
|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
|
|
"value": "99999999999"
|
|
} ],
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "professional"
|
|
} ]
|
|
},
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|
"use": "claim",
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|
"patient": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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|
"billablePeriod": {
|
|
"start": "2014-09-19T22:48:10+02:00",
|
|
"end": "2015-09-19T22:48:10+02:00"
|
|
},
|
|
"created": "2014-09-19T22:48:10+02:00",
|
|
"insurer": {
|
|
"display": "Anthem"
|
|
},
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"facility": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
|
|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:f753a40e-44e9-7e21-4b8e-01ca23d5ade3"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [ {
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
|
|
},
|
|
"role": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary provider"
|
|
} ]
|
|
}
|
|
} ],
|
|
"diagnosis": [ {
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|
"sequence": 1,
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|
"diagnosisReference": {
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"reference": "urn:uuid:4fee0291-8872-f64a-16d9-c02bba20eb76"
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|
},
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|
"type": [ {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
|
|
"code": "principal"
|
|
} ]
|
|
} ]
|
|
} ],
|
|
"insurance": [ {
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Anthem"
|
|
}
|
|
} ],
|
|
"item": [ {
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|
"sequence": 1,
|
|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
|
|
"text": "Well child visit (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-09-19T22:33:10+02:00",
|
|
"end": "2014-09-19T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"encounter": [ {
|
|
"reference": "urn:uuid:18cfb879-6c94-f4b7-18b1-f79c5104d0f5"
|
|
} ]
|
|
}, {
|
|
"sequence": 2,
|
|
"informationSequence": [ 1 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "10",
|
|
"display": "IPV"
|
|
} ],
|
|
"text": "IPV"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-09-19T22:33:10+02:00",
|
|
"end": "2014-09-19T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 3,
|
|
"informationSequence": [ 2 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2014-09-19T22:33:10+02:00",
|
|
"end": "2014-09-19T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 4,
|
|
"informationSequence": [ 3 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "20",
|
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"display": "DTaP"
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} ],
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}
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} ]
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"code": "133",
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"code": "EMER"
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"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e",
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"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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|
} ],
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"end": "2014-11-16T22:33:10+01:00"
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|
},
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|
"individual": {
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|
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}
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} ],
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},
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"system": "http://snomed.info/sct",
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} ]
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} ],
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"location": {
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|
"code": "info"
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|
} ]
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},
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"valueReference": {
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|
"reference": "urn:uuid:02f101fc-f49c-d726-a5c6-24d00f97d3e0"
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}
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} ],
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"procedure": [ {
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"sequence": 1,
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"procedureReference": {
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"reference": "urn:uuid:2075836a-2e10-84c6-e3fa-5fa27ce0e5c6"
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}
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} ],
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"insurance": [ {
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"sequence": 1,
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"focal": true,
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"coverage": {
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"display": "Anthem"
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|
}
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|
} ],
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"item": [ {
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"sequence": 1,
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"productOrService": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "410620009",
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|
"display": "Well child visit (procedure)"
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|
} ],
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"text": "Well child visit (procedure)"
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},
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"encounter": [ {
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"reference": "urn:uuid:d51f6bd0-1fd4-008e-f75c-150452f693e8"
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} ]
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}, {
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"sequence": 2,
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"informationSequence": [ 1 ],
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"productOrService": {
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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "49",
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"display": "Hib (PRP-OMP)"
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|
} ],
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"text": "Hib (PRP-OMP)"
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},
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"net": {
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"value": 136.00,
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"currency": "USD"
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}
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}, {
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"sequence": 3,
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"informationSequence": [ 2 ],
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"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "21",
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|
"display": "varicella"
|
|
} ],
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|
"text": "varicella"
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|
},
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|
"net": {
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|
"value": 136.00,
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|
"currency": "USD"
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|
}
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|
}, {
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"sequence": 4,
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|
"informationSequence": [ 3 ],
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "03",
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|
"display": "MMR"
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|
} ],
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|
"text": "MMR"
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|
},
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"net": {
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|
"value": 136.00,
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|
"currency": "USD"
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}
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}, {
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"sequence": 5,
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"informationSequence": [ 4 ],
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"productOrService": {
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "133",
|
|
"display": "Pneumococcal conjugate PCV 13"
|
|
} ],
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|
"text": "Pneumococcal conjugate PCV 13"
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|
},
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|
"net": {
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|
"value": 136.00,
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|
"currency": "USD"
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|
}
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|
}, {
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"sequence": 6,
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|
"informationSequence": [ 5 ],
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"productOrService": {
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "83",
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|
"display": "Hep A, ped/adol, 2 dose"
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|
} ],
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"text": "Hep A, ped/adol, 2 dose"
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|
},
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"net": {
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"value": 136.00,
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"currency": "USD"
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}
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}, {
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"sequence": 7,
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"procedureSequence": [ 1 ],
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"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
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|
"code": "430193006",
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|
"display": "Medication Reconciliation (procedure)"
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|
} ],
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"text": "Medication Reconciliation (procedure)"
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|
},
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|
"net": {
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|
"value": 703.32,
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"currency": "USD"
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}
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|
} ],
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"total": {
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|
"value": 1520.12,
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|
"currency": "USD"
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|
}
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|
},
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"request": {
|
|
"method": "POST",
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|
"url": "Claim"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:1a0f55c2-800a-9103-019c-3f42a89ff356",
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"resource": {
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"resourceType": "ExplanationOfBenefit",
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"id": "1a0f55c2-800a-9103-019c-3f42a89ff356",
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"contained": [ {
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"resourceType": "ServiceRequest",
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"id": "referral",
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"status": "completed",
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"intent": "order",
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"subject": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"requester": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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|
},
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"performer": [ {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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|
} ]
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}, {
|
|
"resourceType": "Coverage",
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|
"id": "coverage",
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|
"status": "active",
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|
"type": {
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|
"text": "Anthem"
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|
},
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"beneficiary": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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"payor": [ {
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|
"display": "Anthem"
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|
} ]
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|
} ],
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"identifier": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
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"value": "03afa0f2-6cfe-d20d-e452-340850ee68de"
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}, {
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|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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"value": "99999999999"
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|
} ],
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"status": "active",
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"type": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
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"code": "professional"
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|
} ]
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},
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"use": "claim",
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"patient": {
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|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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"billablePeriod": {
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|
"start": "2015-03-20T21:48:10+01:00",
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"end": "2016-03-20T21:48:10+01:00"
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},
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"created": "2015-03-20T21:48:10+01:00",
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"insurer": {
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"display": "Anthem"
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|
},
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"provider": {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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|
},
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|
"referral": {
|
|
"reference": "#referral"
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|
},
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|
"facility": {
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|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
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|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
},
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|
"claim": {
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|
"reference": "urn:uuid:03afa0f2-6cfe-d20d-e452-340850ee68de"
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|
},
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"outcome": "complete",
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"careTeam": [ {
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"sequence": 1,
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|
"provider": {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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|
},
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|
"role": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary provider"
|
|
} ]
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|
}
|
|
} ],
|
|
"insurance": [ {
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|
"focal": true,
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|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Anthem"
|
|
}
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|
} ],
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"item": [ {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
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|
"display": "Medical care"
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|
} ]
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},
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|
"productOrService": {
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|
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|
"system": "http://snomed.info/sct",
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|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
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|
} ],
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|
"text": "Well child visit (procedure)"
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|
},
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|
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"end": "2015-03-20T21:48:10+01:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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} ]
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},
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"encounter": [ {
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|
"reference": "urn:uuid:d51f6bd0-1fd4-008e-f75c-150452f693e8"
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} ]
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}, {
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "49",
|
|
"display": "Hib (PRP-OMP)"
|
|
} ],
|
|
"text": "Hib (PRP-OMP)"
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|
},
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|
"servicedPeriod": {
|
|
"start": "2015-03-20T21:33:10+01:00",
|
|
"end": "2015-03-20T21:48:10+01:00"
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|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
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|
"adjudication": [ {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
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|
}
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|
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
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|
"amount": {
|
|
"value": 108.80000000000001,
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|
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|
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|
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|
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
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|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 3,
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|
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
|
|
"display": "Medical care"
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|
} ]
|
|
},
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "21",
|
|
"display": "varicella"
|
|
} ],
|
|
"text": "varicella"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2015-03-20T21:33:10+01:00",
|
|
"end": "2015-03-20T21:48:10+01:00"
|
|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
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|
"net": {
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|
"value": 136.00,
|
|
"currency": "USD"
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|
},
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
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|
"amount": {
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|
"value": 27.200000000000003,
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|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
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|
"currency": "USD"
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|
}
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|
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
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|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 4,
|
|
"informationSequence": [ 3 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
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|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "03",
|
|
"display": "MMR"
|
|
} ],
|
|
"text": "MMR"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2015-03-20T21:33:10+01:00",
|
|
"end": "2015-03-20T21:48:10+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
},
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|
"adjudication": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
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"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 27.200000000000003,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 3,
|
|
"diagnosisSequence": [ 1 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "314529007",
|
|
"display": "Medication review due (situation)"
|
|
} ],
|
|
"text": "Medication review due (situation)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2015-06-19T22:33:10+02:00",
|
|
"end": "2015-06-19T22:48:10+02:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
}
|
|
} ],
|
|
"total": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
} ],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 272.80,
|
|
"currency": "USD"
|
|
}
|
|
} ],
|
|
"payment": {
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:a2640468-4717-03fd-61eb-83b32d1fc2c2",
|
|
"resource": {
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|
"resourceType": "Encounter",
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|
"id": "a2640468-4717-03fd-61eb-83b32d1fc2c2",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
|
|
},
|
|
"identifier": [ {
|
|
"use": "official",
|
|
"system": "https://github.com/synthetichealth/synthea",
|
|
"value": "a2640468-4717-03fd-61eb-83b32d1fc2c2"
|
|
} ],
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|
"status": "finished",
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|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
|
|
"code": "AMB"
|
|
},
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
|
|
"text": "Well child visit (procedure)"
|
|
} ],
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e",
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|
"display": "Donnell534 Ted955 Koss676"
|
|
},
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|
"participant": [ {
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|
"type": [ {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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|
"code": "PPRF",
|
|
"display": "primary performer"
|
|
} ],
|
|
"text": "primary performer"
|
|
} ],
|
|
"period": {
|
|
"start": "2015-12-18T21:33:10+01:00",
|
|
"end": "2015-12-18T21:48:10+01:00"
|
|
},
|
|
"individual": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094",
|
|
"display": "Dr. Ester635 Baca589"
|
|
}
|
|
} ],
|
|
"period": {
|
|
"start": "2015-12-18T21:33:10+01:00",
|
|
"end": "2015-12-18T21:48:10+01:00"
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|
},
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|
"location": [ {
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|
"location": {
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|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
|
|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
}
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|
} ],
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|
"serviceProvider": {
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|
"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|a4b91172-69e7-3895-bd89-b9a0868de5c2",
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|
"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
|
|
}
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|
},
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|
"request": {
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|
"method": "POST",
|
|
"url": "Encounter"
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|
}
|
|
}, {
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|
"fullUrl": "urn:uuid:043e1e10-dd8f-a5aa-a5f2-feacc1c0dc9f",
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"resource": {
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"resourceType": "Observation",
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|
"id": "043e1e10-dd8f-a5aa-a5f2-feacc1c0dc9f",
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"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-height" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
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|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8302-2",
|
|
"display": "Body Height"
|
|
} ],
|
|
"text": "Body Height"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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},
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},
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|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
|
|
"issued": "2015-12-18T21:33:10.614+01:00",
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|
"valueQuantity": {
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|
"value": 88.9,
|
|
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|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "cm"
|
|
}
|
|
},
|
|
"request": {
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|
"method": "POST",
|
|
"url": "Observation"
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|
}
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|
}, {
|
|
"fullUrl": "urn:uuid:1b021fa3-5620-2dc0-83e5-2a00f99e28ee",
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"resource": {
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|
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|
"code": "vital-signs",
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|
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|
|
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|
} ],
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|
"code": {
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|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72514-3",
|
|
"display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
|
|
} ],
|
|
"text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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|
"encounter": {
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|
"reference": "urn:uuid:a2640468-4717-03fd-61eb-83b32d1fc2c2"
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|
},
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|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
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|
"issued": "2015-12-18T21:33:10.614+01:00",
|
|
"valueQuantity": {
|
|
"value": 1,
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|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
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|
"request": {
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|
"method": "POST",
|
|
"url": "Observation"
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|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:3be66966-f554-96b5-765f-aa1646524dfc",
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|
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|
"resourceType": "Observation",
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|
"id": "3be66966-f554-96b5-765f-aa1646524dfc",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-weight" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
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|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
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|
"display": "Vital signs"
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|
} ]
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|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "29463-7",
|
|
"display": "Body Weight"
|
|
} ],
|
|
"text": "Body Weight"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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|
"encounter": {
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|
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|
},
|
|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
|
|
"issued": "2015-12-18T21:33:10.614+01:00",
|
|
"valueQuantity": {
|
|
"value": 14.4,
|
|
"unit": "kg",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "kg"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:8134e375-3701-6ae8-29ec-d65c236166a0",
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|
"resource": {
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|
"resourceType": "Observation",
|
|
"id": "8134e375-3701-6ae8-29ec-d65c236166a0",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/pediatric-weight-for-height" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
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|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "77606-2",
|
|
"display": "Weight-for-length Per age and sex"
|
|
} ],
|
|
"text": "Weight-for-length Per age and sex"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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|
"encounter": {
|
|
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|
},
|
|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
|
|
"issued": "2015-12-18T21:33:10.614+01:00",
|
|
"valueQuantity": {
|
|
"value": 91.354,
|
|
"unit": "%",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "%"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:6b04a03b-46e4-65f7-83e3-058c49c327a5",
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|
"resource": {
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|
"resourceType": "Observation",
|
|
"id": "6b04a03b-46e4-65f7-83e3-058c49c327a5",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/head-occipital-frontal-circumference-percentile" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8289-1",
|
|
"display": "Head Occipital-frontal circumference Percentile"
|
|
} ],
|
|
"text": "Head Occipital-frontal circumference Percentile"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a2640468-4717-03fd-61eb-83b32d1fc2c2"
|
|
},
|
|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
|
|
"issued": "2015-12-18T21:33:10.614+01:00",
|
|
"valueQuantity": {
|
|
"value": 74.37,
|
|
"unit": "%",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "%"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:0155f2eb-c294-0eff-3fc3-d3c847e5964a",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "0155f2eb-c294-0eff-3fc3-d3c847e5964a",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-head-circumference" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "9843-4",
|
|
"display": "Head Occipital-frontal circumference"
|
|
} ],
|
|
"text": "Head Occipital-frontal circumference"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a2640468-4717-03fd-61eb-83b32d1fc2c2"
|
|
},
|
|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
|
|
"issued": "2015-12-18T21:33:10.614+01:00",
|
|
"valueQuantity": {
|
|
"value": 49.52,
|
|
"unit": "cm",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "cm"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:98c1c76c-119d-1ce4-17e4-c91cea2b271e",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "98c1c76c-119d-1ce4-17e4-c91cea2b271e",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-blood-pressure" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "85354-9",
|
|
"display": "Blood pressure panel with all children optional"
|
|
} ],
|
|
"text": "Blood pressure panel with all children optional"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:5fcaaba4-cfdf-43a8-95c6-7d9f2fa6905e"
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|
},
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|
"encounter": {
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|
"reference": "urn:uuid:a2640468-4717-03fd-61eb-83b32d1fc2c2"
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|
},
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|
"effectiveDateTime": "2015-12-18T21:33:10+01:00",
|
|
"issued": "2015-12-18T21:33:10.614+01:00",
|
|
"component": [ {
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|
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|
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}
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},
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"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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},
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"claim": {
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"display": "Primary provider"
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} ]
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}
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} ],
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"insurance": [ {
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} ]
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},
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|
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} ]
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},
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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|
} ]
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|
},
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"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "83",
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|
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|
} ],
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|
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},
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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|
},
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|
"net": {
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|
"value": 136.00,
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|
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|
},
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"category": {
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|
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|
"display": "Line Beneficiary Coinsurance Amount"
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|
} ]
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|
},
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|
"amount": {
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|
"value": 27.200000000000003,
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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|
"display": "Line Provider Payment Amount"
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|
} ]
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|
},
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|
"amount": {
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|
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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|
"display": "Line Submitted Charge Amount"
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|
} ]
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},
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"amount": {
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|
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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|
"display": "Line Allowed Charge Amount"
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} ]
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|
},
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"amount": {
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|
"value": 136.00,
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"currency": "USD"
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}
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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|
"display": "Line Beneficiary Part B Deductible Amount"
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|
} ]
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|
},
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|
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|
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|
"currency": "USD"
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}
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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|
"display": "Line Processing Indicator Code"
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|
} ]
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|
}
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|
} ]
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|
} ],
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"total": [ {
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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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|
"code": "submitted",
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|
"display": "Submitted Amount"
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|
} ],
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"text": "Submitted Amount"
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},
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}
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} ],
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"payment": {
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"currency": "USD"
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}
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}
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},
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"request": {
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|
"method": "POST",
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"url": "ExplanationOfBenefit"
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}
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}, {
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"fullUrl": "urn:uuid:26c73d51-fadd-dc75-bb94-c82bca7e3f81",
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"resource": {
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"id": "26c73d51-fadd-dc75-bb94-c82bca7e3f81",
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
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},
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"identifier": [ {
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"id": "coverage",
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} ]
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"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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"value": "99999999999"
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"code": "professional"
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"reference": "urn:uuid:9e4e7a6e-7e2d-52a1-51da-46fec0f15bfb"
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"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
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"code": "principal"
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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"code": "1",
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|
} ]
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|
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|
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|
|
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|
} ],
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|
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|
},
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"code": "19",
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"display": "Off Campus-Outpatient Hospital"
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}
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"code": "1",
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"display": "Medical care"
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|
} ]
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},
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|
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|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
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|
} ],
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|
"text": "Medication Reconciliation (procedure)"
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|
},
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|
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|
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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"display": "Off Campus-Outpatient Hospital"
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} ]
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},
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"display": "Line Beneficiary Coinsurance Amount"
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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"display": "Line Provider Payment Amount"
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} ]
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},
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"amount": {
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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} ]
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},
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Beneficiary Part B Deductible Amount"
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} ]
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},
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"value": 0,
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}
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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"display": "Submitted Amount"
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} ],
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},
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"value": 1380.88,
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}
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},
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"code": "EMER"
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},
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"system": "http://snomed.info/sct",
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"code": "50849002",
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} ],
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} ],
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"display": "Donnell534 Ted955 Koss676"
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"reference": "#coverage",
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"system": "http://hl7.org/fhir/sid/cvx",
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"code": "140",
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"display": "Influenza, seasonal, injectable, preservative free"
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} ],
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},
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} ]
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} ]
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} ]
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},
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} ]
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} ]
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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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}, {
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"code": "314529007",
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"display": "Medication review due (situation)"
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} ],
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},
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"code": "58410-2",
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} ],
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|
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|
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|
|
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|
} ],
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|
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|
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|
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|
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|
|
"code": "29463-7",
|
|
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|
|
} ],
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|
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|
|
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|
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|
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|
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|
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|
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|
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|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-bmi" ]
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|
},
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|
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|
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|
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|
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|
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|
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|
|
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|
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|
"code": {
|
|
"coding": [ {
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|
"system": "http://loinc.org",
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|
"code": "39156-5",
|
|
"display": "Body mass index (BMI) [Ratio]"
|
|
} ],
|
|
"text": "Body mass index (BMI) [Ratio]"
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|
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} ],
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"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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} ],
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},
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},
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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},
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|3b7b36e7-479b-33c5-91c9-bfc6c54d04fe",
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"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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},
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"claim": {
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"reference": "urn:uuid:c8720d0b-beb5-d64a-f7f9-11534e6323a7"
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},
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"outcome": "complete",
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"careTeam": [ {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094"
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"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
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"display": "Primary provider"
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} ]
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}
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} ],
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"insurance": [ {
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"reference": "#coverage",
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"display": "Cigna Health"
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}
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} ],
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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"display": "Medical care"
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} ]
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},
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"productOrService": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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"code": "410620009",
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"display": "Well child visit (procedure)"
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|
} ],
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"text": "Well child visit (procedure)"
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},
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"servicedPeriod": {
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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},
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"encounter": [ {
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"reference": "urn:uuid:0ba0ff39-c3e4-2718-ec34-ddc08c6954a7"
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} ]
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
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|
"display": "Medical care"
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|
} ]
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},
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|
"productOrService": {
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|
"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "140",
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|
"display": "Influenza, seasonal, injectable, preservative free"
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|
} ],
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|
"text": "Influenza, seasonal, injectable, preservative free"
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|
},
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|
"servicedPeriod": {
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|
"start": "2023-01-13T21:33:10+01:00",
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|
"end": "2023-01-13T21:48:10+01:00"
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|
},
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"locationCodeableConcept": {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
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|
"value": 136.00,
|
|
"currency": "USD"
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|
},
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|
"adjudication": [ {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
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|
},
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|
"amount": {
|
|
"value": 27.200000000000003,
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|
"currency": "USD"
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}
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}, {
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"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
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|
"value": 108.80000000000001,
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"currency": "USD"
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|
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"category": {
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|
"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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|
"display": "Line Submitted Charge Amount"
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|
} ]
|
|
},
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|
"amount": {
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|
"value": 136.00,
|
|
"currency": "USD"
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|
}
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|
}, {
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
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|
"amount": {
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|
"value": 136.00,
|
|
"currency": "USD"
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}
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}, {
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
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|
"amount": {
|
|
"value": 0,
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|
"currency": "USD"
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}
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|
}, {
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"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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|
"display": "Line Processing Indicator Code"
|
|
} ]
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|
}
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|
} ]
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|
} ],
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|
"total": [ {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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|
"code": "submitted",
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|
"display": "Submitted Amount"
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|
} ],
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|
"text": "Submitted Amount"
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},
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}
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}, {
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"reference": "urn:uuid:c8720d0b-beb5-d64a-f7f9-11534e6323a7"
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}, {
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"reference": "urn:uuid:f63b49c4-f2a3-35ab-29e2-303711ac814a"
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} ],
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"recorded": "2023-09-08T22:33:10.614+02:00",
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"agent": [ {
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"type": {
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"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/provenance-participant-type",
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|
"code": "author",
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|
"display": "Author"
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|
} ],
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"text": "Author"
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},
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"who": {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094",
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"display": "Dr. Ester635 Baca589"
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|
},
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"onBehalfOf": {
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"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|a4b91172-69e7-3895-bd89-b9a0868de5c2",
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"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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}
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}, {
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"type": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/us/core/CodeSystem/us-core-provenance-participant-type",
|
|
"code": "transmitter",
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|
"display": "Transmitter"
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|
} ],
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|
"text": "Transmitter"
|
|
},
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|
"who": {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999961094",
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|
"display": "Dr. Ester635 Baca589"
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|
},
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"onBehalfOf": {
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|
"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|a4b91172-69e7-3895-bd89-b9a0868de5c2",
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"display": "DARTMOUTH PRIMARY MEDICINE, LLC"
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|
}
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|
} ]
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|
},
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|
"request": {
|
|
"method": "POST",
|
|
"url": "Provenance"
|
|
}
|
|
} ]
|
|
}
|