63092 lines
2.1 MiB
63092 lines
2.1 MiB
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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",
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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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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} ]
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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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"display": "Off Campus-Outpatient Hospital"
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} ]
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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": 6.418000000000001,
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}
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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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"amount": {
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"value": 25.672000000000004,
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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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"value": 32.09,
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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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"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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"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": 7,
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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",
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"code": "89206-7",
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"display": "Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen]"
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} ],
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"text": "Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen]"
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},
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"start": "1993-01-13T19:14:55+01:00",
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"end": "1993-01-13T19:29:55+01:00"
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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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"value": 74.58,
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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_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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}, {
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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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}
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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": 74.58,
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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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} ]
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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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"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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"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_prcsg_ind_cd",
|
|
"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": 8,
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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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"system": "http://snomed.info/sct",
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"code": "428211000124100",
|
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"display": "Assessment of substance use (procedure)"
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|
} ],
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"text": "Assessment of substance use (procedure)"
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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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"value": 431.40,
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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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} ]
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},
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"amount": {
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"value": 86.28,
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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": {
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"value": 345.12,
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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": 431.40,
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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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}
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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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}
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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_prcsg_ind_cd",
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"display": "Line Processing Indicator Code"
|
|
} ]
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}
|
|
} ]
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|
}, {
|
|
"sequence": 9,
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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",
|
|
"display": "Medical care"
|
|
} ]
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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": "868187001",
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|
"display": "Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (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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"value": 431.40,
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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": 86.28,
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"currency": "USD"
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}
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}, {
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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": {
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"value": 345.12,
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"currency": "USD"
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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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}, {
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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": 431.40,
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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",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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},
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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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"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_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 10,
|
|
"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": "386516004",
|
|
"display": "Anticipatory guidance (procedure)"
|
|
} ],
|
|
"text": "Anticipatory guidance (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1993-01-13T19:14:55+01:00",
|
|
"end": "1993-01-13T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
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|
"value": 431.40,
|
|
"currency": "USD"
|
|
},
|
|
"adjudication": [ {
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|
"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": 86.28,
|
|
"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": 345.12,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"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": 431.40,
|
|
"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",
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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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"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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"value": 0,
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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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"code": "AMB"
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},
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"system": "http://snomed.info/sct",
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} ],
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"display": "Ms. Dorthy94 Kelly223 Klocko335"
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"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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"code": "PPRF",
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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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|
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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": "1",
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|
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|
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|
"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
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|
"code": "749785",
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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": "Submitted Amount"
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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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|
|
"url": "ExplanationOfBenefit"
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}
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|
}, {
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"fullUrl": "urn:uuid:163134ca-e1c6-c533-1b32-d87581db81ae",
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|
|
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|
|
"display": "History and physical note"
|
|
}, {
|
|
"system": "http://loinc.org",
|
|
"code": "51847-2",
|
|
"display": "Evaluation + Plan note"
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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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|
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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": "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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"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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}
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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",
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"display": "Line Provider Payment Amount"
|
|
} ]
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},
|
|
"amount": {
|
|
"value": 108.80000000000001,
|
|
"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_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"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"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",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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|
"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": "1994-01-19T19:14:55+01:00",
|
|
"end": "1994-01-19T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
}
|
|
}, {
|
|
"sequence": 4,
|
|
"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": "171207006",
|
|
"display": "Depression screening (procedure)"
|
|
} ],
|
|
"text": "Depression screening (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1994-01-19T19:14:55+01:00",
|
|
"end": "1994-01-19T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 86.28,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"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"
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|
} ]
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|
},
|
|
"amount": {
|
|
"value": 345.12,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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|
"display": "Line Submitted Charge Amount"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 431.40,
|
|
"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_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 431.40,
|
|
"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"
|
|
}
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|
}, {
|
|
"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,
|
|
"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://snomed.info/sct",
|
|
"code": "715252007",
|
|
"display": "Depression screening using Patient Health Questionnaire Nine Item score (procedure)"
|
|
} ],
|
|
"text": "Depression screening using Patient Health Questionnaire Nine Item score (procedure)"
|
|
},
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|
"servicedPeriod": {
|
|
"start": "1994-01-19T19:14:55+01:00",
|
|
"end": "1994-01-19T19:29:55+01:00"
|
|
},
|
|
"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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|
},
|
|
"net": {
|
|
"value": 31.72,
|
|
"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": 6.344,
|
|
"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"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 25.376,
|
|
"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"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 31.72,
|
|
"currency": "USD"
|
|
}
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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_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
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|
} ]
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|
},
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|
"amount": {
|
|
"value": 31.72,
|
|
"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_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
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|
}, {
|
|
"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": 6,
|
|
"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://loinc.org",
|
|
"code": "89206-7",
|
|
"display": "Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen]"
|
|
} ],
|
|
"text": "Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen]"
|
|
},
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|
"servicedPeriod": {
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|
"start": "1994-01-19T19:14:55+01:00",
|
|
"end": "1994-01-19T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 74.58,
|
|
"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": 14.916,
|
|
"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": 59.664,
|
|
"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": 74.58,
|
|
"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"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 74.58,
|
|
"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": 7,
|
|
"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": "428211000124100",
|
|
"display": "Assessment of substance use (procedure)"
|
|
} ],
|
|
"text": "Assessment of substance use (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1994-01-19T19:14:55+01:00",
|
|
"end": "1994-01-19T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"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": 431.40,
|
|
"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"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 431.40,
|
|
"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": 8,
|
|
"category": {
|
|
"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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"system": "http://snomed.info/sct",
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"code": "868187001",
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"display": "Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure)"
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|
} ],
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"text": "Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure)"
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},
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"servicedPeriod": {
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"start": "1994-01-19T19:14:55+01:00",
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"end": "1994-01-19T19:29:55+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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"display": "Off Campus-Outpatient Hospital"
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} ]
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},
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"net": {
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"value": 431.40,
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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_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": 86.28,
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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": 345.12,
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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": 431.40,
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"currency": "USD"
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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": 431.40,
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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_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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}
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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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|
}, {
|
|
"sequence": 9,
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"diagnosisSequence": [ 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://snomed.info/sct",
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|
"code": "160968000",
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|
"display": "Risk activity involvement (finding)"
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} ],
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"text": "Risk activity involvement (finding)"
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},
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"servicedPeriod": {
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"start": "1994-01-19T19:14:55+01:00",
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"end": "1994-01-19T19:29:55+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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}, {
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"sequence": 10,
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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": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "370995009",
|
|
"display": "Health risks education (procedure)"
|
|
} ],
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|
"text": "Health risks education (procedure)"
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|
},
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|
"servicedPeriod": {
|
|
"start": "1994-01-19T19:14:55+01:00",
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"end": "1994-01-19T19:29:55+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": 431.40,
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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_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": 86.28,
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"display": "Line Provider Payment Amount"
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},
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"amount": {
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"value": 345.12,
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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} ],
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"value": 704.20,
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}
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"value": 1574.3200000000002,
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},
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"request": {
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"method": "POST",
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|
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}
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}, {
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"fullUrl": "urn:uuid:6aafda4b-2c34-ac59-5673-f38106dce87b",
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},
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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",
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|
"code": "698314001",
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|
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|
} ],
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"text": "Consultation for treatment"
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"subject": {
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"display": "Ms. Dorthy94 Kelly223 Klocko335"
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"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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},
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"individual": {
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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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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|d11f97b5-721f-3bcd-8c00-973ba1f8f1b3",
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"fullUrl": "urn:uuid:a76e4c8f-3195-6bb0-02e5-dd44b28a411a",
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|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest" ]
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|
},
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|
"status": "stopped",
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|
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|
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"system": "http://terminology.hl7.org/CodeSystem/medicationrequest-category",
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|
"code": "community",
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|
"display": "Community"
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|
} ],
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|
"text": "Community"
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|
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|
"medicationCodeableConcept": {
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|
"coding": [ {
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|
"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
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|
"code": "749882",
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|
"display": "Norinyl 1+50 28 Day Pack"
|
|
} ],
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"text": "Norinyl 1+50 28 Day Pack"
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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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|
"fullUrl": "urn:uuid:194b1ad0-fee7-ef13-8a84-c863090f054d",
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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": "http://terminology.hl7.org/CodeSystem/claim-type",
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|
"code": "pharmacy"
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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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|
"provider": {
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|
"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|a2cc09de-c1e2-3126-8c09-d49f95225281",
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|
"display": "CHILDREN'S HOSPITAL CORPORATION"
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|
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|
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
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|
"code": "normal"
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|
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|
},
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|
"prescription": {
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|
"reference": "urn:uuid:a76e4c8f-3195-6bb0-02e5-dd44b28a411a"
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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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|
"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
|
|
"code": "749882",
|
|
"display": "Norinyl 1+50 28 Day Pack"
|
|
} ],
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|
"text": "Norinyl 1+50 28 Day Pack"
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|
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|
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|
"reference": "urn:uuid:6aafda4b-2c34-ac59-5673-f38106dce87b"
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|
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|
"value": 612.39,
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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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|
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|
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|
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"resource": {
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|
"resourceType": "ExplanationOfBenefit",
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|
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|
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|
"resourceType": "ServiceRequest",
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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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|
}, {
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Humana"
|
|
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|
|
"beneficiary": {
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|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"payor": [ {
|
|
"display": "Humana"
|
|
} ]
|
|
} ],
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|
"identifier": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "194b1ad0-fee7-ef13-8a84-c863090f054d"
|
|
}, {
|
|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
|
|
"value": "99999999999"
|
|
} ],
|
|
"status": "active",
|
|
"type": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
|
|
"code": "pharmacy"
|
|
} ]
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|
},
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|
"use": "claim",
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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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|
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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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|
"system": "http://loinc.org",
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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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|
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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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|
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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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|
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|
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|
} ],
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|
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|
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|
|
"code": "32623-1",
|
|
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|
|
} ],
|
|
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|
},
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},
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"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"requester": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"performer": [ {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
} ]
|
|
}, {
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Humana"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"payor": [ {
|
|
"display": "Humana"
|
|
} ]
|
|
} ],
|
|
"identifier": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "a7107bc9-2553-19dd-7137-f819fbfea3f9"
|
|
}, {
|
|
"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:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "1995-01-25T19:35:06+01:00",
|
|
"end": "1996-01-25T19:35:06+01:00"
|
|
},
|
|
"created": "1995-01-25T19:35:06+01:00",
|
|
"insurer": {
|
|
"display": "Humana"
|
|
},
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"facility": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:a7107bc9-2553-19dd-7137-f819fbfea3f9"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [ {
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"role": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary provider"
|
|
} ]
|
|
}
|
|
} ],
|
|
"insurance": [ {
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Humana"
|
|
}
|
|
} ],
|
|
"item": [ {
|
|
"sequence": 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": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
|
|
"text": "Well child visit (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1995-01-25T19:14:55+01:00",
|
|
"end": "1995-01-25T19:35:06+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"encounter": [ {
|
|
"reference": "urn:uuid:9f7d3dc0-5d73-84d7-94ef-cd1b563e2e41"
|
|
} ]
|
|
}, {
|
|
"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": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1995-01-25T19:14:55+01:00",
|
|
"end": "1995-01-25T19:35:06+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"
|
|
},
|
|
"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,
|
|
"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": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1995-01-25T19:14:55+01:00",
|
|
"end": "1995-01-25T19:35:06+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 531.12,
|
|
"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": 106.224,
|
|
"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": 424.896,
|
|
"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": 531.12,
|
|
"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": 531.12,
|
|
"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": [ 2 ],
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "58410-2",
|
|
"display": "CBC panel - Blood by Automated count"
|
|
} ],
|
|
"text": "CBC panel - Blood by Automated count"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1995-01-25T19:14:55+01:00",
|
|
"end": "1995-01-25T19:35:06+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 74.58,
|
|
"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": 14.916,
|
|
"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": 59.664,
|
|
"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": 74.58,
|
|
"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": 74.58,
|
|
"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": 5,
|
|
"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": "710841007",
|
|
"display": "Assessment of anxiety (procedure)"
|
|
} ],
|
|
"text": "Assessment of anxiety (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1995-01-25T19:14:55+01:00",
|
|
"end": "1995-01-25T19:35:06+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"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": 431.40,
|
|
"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": 431.40,
|
|
"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"
|
|
} ]
|
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},
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"value": 0,
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"currency": "USD"
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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_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": 6,
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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",
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"code": "69737-5",
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"display": "Generalized anxiety disorder 7 item (GAD-7)"
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} ],
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"text": "Generalized anxiety disorder 7 item (GAD-7)"
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},
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"start": "1995-01-25T19:14:55+01:00",
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"end": "1995-01-25T19:35:06+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": 74.58,
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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_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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"currency": "USD"
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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_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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"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": 74.58,
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"value": 74.58,
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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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"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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|
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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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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
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|
"code": "171207006",
|
|
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|
} ],
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},
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"start": "1995-01-25T19:14:55+01:00",
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"end": "1995-01-25T19:35:06+01:00"
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},
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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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"net": {
|
|
"value": 431.40,
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|
"currency": "USD"
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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_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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"value": 86.28,
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}
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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},
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|
"value": 345.12,
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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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"value": 431.40,
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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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"value": 431.40,
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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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"value": 0,
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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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"system": "http://snomed.info/sct",
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"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"system": "http://loinc.org",
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} ],
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"text": "Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen]"
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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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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"value": 14.916,
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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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|
"total": [ {
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|
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|
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|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
} ],
|
|
"text": "Submitted Amount"
|
|
},
|
|
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|
|
"value": 1309.90,
|
|
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|
|
}
|
|
} ],
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|
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|
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|
|
"value": 1426.4,
|
|
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|
|
}
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|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
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|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:9c93d287-5c55-ed81-c2e5-17b96a78ab37",
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|
"resource": {
|
|
"resourceType": "Encounter",
|
|
"id": "9c93d287-5c55-ed81-c2e5-17b96a78ab37",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
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|
},
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|
"identifier": [ {
|
|
"use": "official",
|
|
"system": "https://github.com/synthetichealth/synthea",
|
|
"value": "9c93d287-5c55-ed81-c2e5-17b96a78ab37"
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|
} ],
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|
"status": "finished",
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|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
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|
"code": "AMB"
|
|
},
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "185345009",
|
|
"display": "Encounter for symptom"
|
|
} ],
|
|
"text": "Encounter for symptom"
|
|
} ],
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|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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|
"display": "Ms. Dorthy94 Kelly223 Klocko335"
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|
},
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|
"participant": [ {
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|
"type": [ {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
|
|
"code": "PPRF",
|
|
"display": "primary performer"
|
|
} ],
|
|
"text": "primary performer"
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|
} ],
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|
"period": {
|
|
"start": "1995-05-15T09:14:55+02:00",
|
|
"end": "1995-05-15T09:29:55+02:00"
|
|
},
|
|
"individual": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895",
|
|
"display": "Dr. Patrina117 Strosin214"
|
|
}
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|
} ],
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|
"period": {
|
|
"start": "1995-05-15T09:14:55+02:00",
|
|
"end": "1995-05-15T09:29:55+02:00"
|
|
},
|
|
"reasonCode": [ {
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|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "444814009",
|
|
"display": "Viral sinusitis (disorder)"
|
|
} ]
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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|5e756e0c-7c6b-37c0-8bd5-eebe86c41e5e",
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"system": "http://unitsofmeasure.org",
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"code": "cm"
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}
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},
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"method": "POST",
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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": "72514-3",
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"display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
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} ],
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"text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
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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-body-weight" ]
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},
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} ],
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"code": {
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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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"value": 64,
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"code": "kg"
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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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"status": "final",
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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": "39156-5",
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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/pediatric-bmi-for-age" ]
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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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|
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|
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|
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|
|
"type": {
|
|
"text": "Humana"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"payor": [ {
|
|
"display": "Humana"
|
|
} ]
|
|
} ],
|
|
"identifier": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "a4a637b4-3ba4-aa74-b545-731ea069bd9c"
|
|
}, {
|
|
"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:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"billablePeriod": {
|
|
"start": "1996-01-31T19:29:55+01:00",
|
|
"end": "1997-01-31T19:29:55+01:00"
|
|
},
|
|
"created": "1996-01-31T19:29:55+01:00",
|
|
"insurer": {
|
|
"display": "Humana"
|
|
},
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"facility": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:a4a637b4-3ba4-aa74-b545-731ea069bd9c"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [ {
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"role": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
|
|
"code": "primary",
|
|
"display": "Primary provider"
|
|
} ]
|
|
}
|
|
} ],
|
|
"diagnosis": [ {
|
|
"sequence": 1,
|
|
"diagnosisReference": {
|
|
"reference": "urn:uuid:c2a9f2af-7441-e9ef-b13e-2d4a70027d1a"
|
|
},
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
|
|
"code": "principal"
|
|
} ]
|
|
} ]
|
|
} ],
|
|
"insurance": [ {
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Humana"
|
|
}
|
|
} ],
|
|
"item": [ {
|
|
"sequence": 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": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
|
|
"text": "Well child visit (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1996-01-31T19:14:55+01:00",
|
|
"end": "1996-01-31T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"encounter": [ {
|
|
"reference": "urn:uuid:b286b8ed-4252-5eee-2156-3f4b75bc32fb"
|
|
} ]
|
|
}, {
|
|
"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": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1996-01-31T19:14:55+01:00",
|
|
"end": "1996-01-31T19:29:55+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"
|
|
},
|
|
"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,
|
|
"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": "1996-01-31T19:14:55+01:00",
|
|
"end": "1996-01-31T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
}
|
|
}, {
|
|
"sequence": 4,
|
|
"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": "428211000124100",
|
|
"display": "Assessment of substance use (procedure)"
|
|
} ],
|
|
"text": "Assessment of substance use (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1996-01-31T19:14:55+01:00",
|
|
"end": "1996-01-31T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"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": 431.40,
|
|
"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": 431.40,
|
|
"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": 5,
|
|
"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": "868187001",
|
|
"display": "Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure)"
|
|
} ],
|
|
"text": "Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1996-01-31T19:14:55+01:00",
|
|
"end": "1996-01-31T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"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": 431.40,
|
|
"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": 431.40,
|
|
"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": 6,
|
|
"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": "386516004",
|
|
"display": "Anticipatory guidance (procedure)"
|
|
} ],
|
|
"text": "Anticipatory guidance (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1996-01-31T19:14:55+01:00",
|
|
"end": "1996-01-31T19:29:55+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"category": {
|
|
"coding": [ {
|
|
"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": 431.40,
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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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}
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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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"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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"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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"amount": {
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"value": 704.20,
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}
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} ],
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"payment": {
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"amount": {
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"value": 1144.1599999999999,
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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:93263194-3a3e-e1df-1a9b-60f8c066ce3f",
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
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},
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"use": "official",
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"value": "93263194-3a3e-e1df-1a9b-60f8c066ce3f"
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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": "EMER"
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},
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"type": [ {
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"coding": [ {
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"system": "http://snomed.info/sct",
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"code": "50849002",
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} ],
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"text": "Emergency room admission (procedure)"
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} ],
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"subject": {
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"display": "Ms. Dorthy94 Kelly223 Klocko335"
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},
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"type": [ {
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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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} ],
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} ],
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"end": "1996-10-23T23:21:03+02:00"
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},
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"individual": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999895797",
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}
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} ],
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},
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"coding": [ {
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"system": "http://snomed.info/sct",
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"code": "125605004",
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} ]
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} ],
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"location": [ {
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"location": {
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"display": "MARISTHILL NURSING & REHABILITATION CENTER"
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}
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"serviceProvider": {
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"display": "MARISTHILL NURSING & REHABILITATION CENTER"
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}
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"text": "Fracture of clavicle"
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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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|
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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": "community",
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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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|
"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
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|
"code": "1049221",
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|
"display": "Acetaminophen 325 MG / oxyCODONE Hydrochloride 5 MG Oral Tablet"
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|
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|
"text": "Acetaminophen 325 MG / oxyCODONE Hydrochloride 5 MG Oral Tablet"
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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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|
|
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|
|
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|
|
"code": "ordered",
|
|
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|
|
} ]
|
|
},
|
|
"doseQuantity": {
|
|
"value": 1.0
|
|
}
|
|
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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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|
|
"fullUrl": "urn:uuid:cee1499e-4297-ad72-67d5-2539c5725347",
|
|
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|
|
"resourceType": "Claim",
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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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"provider": {
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|
"display": "MARISTHILL NURSING & REHABILITATION CENTER"
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|
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|
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
|
|
"code": "normal"
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|
} ]
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|
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|
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|
"reference": "urn:uuid:2ede3759-e924-e1f2-9fcf-c2ad54bf82ce"
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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": "Humana"
|
|
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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": "http://www.nlm.nih.gov/research/umls/rxnorm",
|
|
"code": "1049221",
|
|
"display": "Acetaminophen 325 MG / oxyCODONE Hydrochloride 5 MG Oral Tablet"
|
|
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|
"text": "Acetaminophen 325 MG / oxyCODONE Hydrochloride 5 MG Oral Tablet"
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|
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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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|
"value": 7.41,
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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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|
},
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} ]
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|
"resourceType": "Coverage",
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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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|
"display": "Respiratory rate"
|
|
} ],
|
|
"text": "Respiratory rate"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:2f3e9b27-b1bb-4bb2-8056-240096bcb99c"
|
|
},
|
|
"effectiveDateTime": "1997-02-05T19:14:55+01:00",
|
|
"issued": "1997-02-05T19:14:55.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 13,
|
|
"unit": "/min",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/min"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:4c2c56f3-2c25-3b73-2512-475e8bdf9a56",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "4c2c56f3-2c25-3b73-2512-475e8bdf9a56",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "social-history",
|
|
"display": "Social history"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72166-2",
|
|
"display": "Tobacco smoking status"
|
|
} ],
|
|
"text": "Tobacco smoking status"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:2f3e9b27-b1bb-4bb2-8056-240096bcb99c"
|
|
},
|
|
"effectiveDateTime": "1997-02-05T19:14:55+01:00",
|
|
"issued": "1997-02-05T19:14:55.153+01:00",
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "266919005",
|
|
"display": "Never smoked tobacco (finding)"
|
|
} ],
|
|
"text": "Never smoked tobacco (finding)"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:bb776788-cab1-9380-e78b-325f489089ab",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "bb776788-cab1-9380-e78b-325f489089ab",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93025-5",
|
|
"display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
} ],
|
|
"text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:2f3e9b27-b1bb-4bb2-8056-240096bcb99c"
|
|
},
|
|
"effectiveDateTime": "1997-02-05T19:45:13+01:00",
|
|
"issued": "1997-02-05T19:45:13.153+01:00",
|
|
"component": [ {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76501-6",
|
|
"display": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
} ],
|
|
"text": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93026-3",
|
|
"display": "Do you feel physically and emotionally safe where you currently live?"
|
|
} ],
|
|
"text": "Do you feel physically and emotionally safe where you currently live?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA33-6",
|
|
"display": "Yes"
|
|
} ],
|
|
"text": "Yes"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93027-1",
|
|
"display": "Are you a refugee?"
|
|
} ],
|
|
"text": "Are you a refugee?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93028-9",
|
|
"display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
} ],
|
|
"text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93038-8",
|
|
"display": "Stress level"
|
|
} ],
|
|
"text": "Stress level"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6568-5",
|
|
"display": "Not at all"
|
|
} ],
|
|
"text": "Not at all"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93029-7",
|
|
"display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
} ],
|
|
"text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30132-7",
|
|
"display": "5 or more times a week"
|
|
} ],
|
|
"text": "5 or more times a week"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93030-5",
|
|
"display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
} ],
|
|
"text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93031-3",
|
|
"display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
} ],
|
|
"text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30128-5",
|
|
"display": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)"
|
|
} ],
|
|
"text": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63586-2",
|
|
"display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
} ],
|
|
"text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 121160,
|
|
"unit": "/a",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/a"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76437-3",
|
|
"display": "Primary insurance"
|
|
} ],
|
|
"text": "Primary insurance"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6350-8",
|
|
"display": "Private insurance"
|
|
} ],
|
|
"text": "Private insurance"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "67875-5",
|
|
"display": "Employment status - current"
|
|
} ],
|
|
"text": "Employment status - current"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30137-6",
|
|
"display": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
|
|
} ],
|
|
"text": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "82589-3",
|
|
"display": "Highest level of education"
|
|
} ],
|
|
"text": "Highest level of education"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30192-1",
|
|
"display": "High school diploma or GED"
|
|
} ],
|
|
"text": "High school diploma or GED"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56799-0",
|
|
"display": "Address"
|
|
} ],
|
|
"text": "Address"
|
|
},
|
|
"valueString": "1082 Weissnat Arcade"
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93033-9",
|
|
"display": "Are you worried about losing your housing?"
|
|
} ],
|
|
"text": "Are you worried about losing your housing?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "71802-3",
|
|
"display": "Housing status"
|
|
} ],
|
|
"text": "Housing status"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30189-7",
|
|
"display": "I have housing"
|
|
} ],
|
|
"text": "I have housing"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63512-8",
|
|
"display": "How many people are living or staying at this address?"
|
|
} ],
|
|
"text": "How many people are living or staying at this address?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 5,
|
|
"unit": "{#}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{#}"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "54899-0",
|
|
"display": "Preferred language"
|
|
} ],
|
|
"text": "Preferred language"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA43-5",
|
|
"display": "English"
|
|
} ],
|
|
"text": "English"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93034-7",
|
|
"display": "Have you been discharged from the armed forces of the United States?"
|
|
} ],
|
|
"text": "Have you been discharged from the armed forces of the United States?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93035-4",
|
|
"display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
} ],
|
|
"text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "32624-9",
|
|
"display": "Race"
|
|
} ],
|
|
"text": "Race"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA4457-3",
|
|
"display": "White"
|
|
} ],
|
|
"text": "White"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56051-6",
|
|
"display": "Do you consider yourself Hispanic/Latino?"
|
|
} ],
|
|
"text": "Do you consider yourself Hispanic/Latino?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:37fecfe6-4d49-fc28-274c-6f6d79bccc45",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "37fecfe6-4d49-fc28-274c-6f6d79bccc45",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "55758-7",
|
|
"display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
} ],
|
|
"text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:2f3e9b27-b1bb-4bb2-8056-240096bcb99c"
|
|
},
|
|
"effectiveDateTime": "1997-02-05T20:22:56+01:00",
|
|
"issued": "1997-02-05T20:22:56.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 1,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:5258cc13-c919-9cba-e8dc-af557d87f8a4",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "5258cc13-c919-9cba-e8dc-af557d87f8a4",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
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"coding": [ {
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"net": {
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"value": 431.40,
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"currency": "USD"
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}
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}, {
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"sequence": 12,
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|
"informationSequence": [ 3 ],
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72109-2",
|
|
"display": "Alcohol Use Disorder Identification Test - Consumption [AUDIT-C]"
|
|
} ],
|
|
"text": "Alcohol Use Disorder Identification Test - Consumption [AUDIT-C]"
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|
},
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"net": {
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|
"value": 74.58,
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|
"currency": "USD"
|
|
}
|
|
} ],
|
|
"total": {
|
|
"value": 1286.77,
|
|
"currency": "USD"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Claim"
|
|
}
|
|
}, {
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|
"fullUrl": "urn:uuid:26a0f530-bbd2-dfdf-00a1-0f6b669b478c",
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"resource": {
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|
"resourceType": "ExplanationOfBenefit",
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"id": "26a0f530-bbd2-dfdf-00a1-0f6b669b478c",
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|
"contained": [ {
|
|
"resourceType": "ServiceRequest",
|
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"id": "referral",
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"status": "completed",
|
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"intent": "order",
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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|
},
|
|
"requester": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"performer": [ {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
} ]
|
|
}, {
|
|
"resourceType": "Coverage",
|
|
"id": "coverage",
|
|
"status": "active",
|
|
"type": {
|
|
"text": "Humana"
|
|
},
|
|
"beneficiary": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"payor": [ {
|
|
"display": "Humana"
|
|
} ]
|
|
} ],
|
|
"identifier": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "b233c855-581d-c163-f8e6-1f523aa22d7a"
|
|
}, {
|
|
"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",
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|
"patient": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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|
},
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|
"billablePeriod": {
|
|
"start": "1997-02-05T19:45:13+01:00",
|
|
"end": "1998-02-05T19:45:13+01:00"
|
|
},
|
|
"created": "1997-02-05T19:45:13+01:00",
|
|
"insurer": {
|
|
"display": "Humana"
|
|
},
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"referral": {
|
|
"reference": "#referral"
|
|
},
|
|
"facility": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
},
|
|
"claim": {
|
|
"reference": "urn:uuid:b233c855-581d-c163-f8e6-1f523aa22d7a"
|
|
},
|
|
"outcome": "complete",
|
|
"careTeam": [ {
|
|
"sequence": 1,
|
|
"provider": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
|
|
},
|
|
"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:d553b8bb-c44f-9a64-76a9-6a69c3e39d5d"
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|
},
|
|
"type": [ {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
|
|
"code": "principal"
|
|
} ]
|
|
} ]
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|
}, {
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|
"sequence": 2,
|
|
"diagnosisReference": {
|
|
"reference": "urn:uuid:7f83d5d1-67e4-efe4-fec0-6559cb077c5a"
|
|
},
|
|
"type": [ {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
|
|
"code": "principal"
|
|
} ]
|
|
} ]
|
|
} ],
|
|
"insurance": [ {
|
|
"focal": true,
|
|
"coverage": {
|
|
"reference": "#coverage",
|
|
"display": "Humana"
|
|
}
|
|
} ],
|
|
"item": [ {
|
|
"sequence": 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": "162673000",
|
|
"display": "General examination of patient (procedure)"
|
|
} ],
|
|
"text": "General examination of patient (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1997-02-05T19:14:55+01:00",
|
|
"end": "1997-02-05T19:45:13+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"encounter": [ {
|
|
"reference": "urn:uuid:2f3e9b27-b1bb-4bb2-8056-240096bcb99c"
|
|
} ]
|
|
}, {
|
|
"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": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1997-02-05T19:14:55+01:00",
|
|
"end": "1997-02-05T19:45:13+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"
|
|
},
|
|
"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,
|
|
"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": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1997-02-05T19:14:55+01:00",
|
|
"end": "1997-02-05T19:45:13+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 582.57,
|
|
"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": 116.51400000000001,
|
|
"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": 466.05600000000004,
|
|
"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": 582.57,
|
|
"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": 582.57,
|
|
"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,
|
|
"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": "710824005",
|
|
"display": "Assessment of health and social care needs (procedure)"
|
|
} ],
|
|
"text": "Assessment of health and social care needs (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1997-02-05T19:14:55+01:00",
|
|
"end": "1997-02-05T19:45:13+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"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": 431.40,
|
|
"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": 431.40,
|
|
"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": 5,
|
|
"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": "5251000175109",
|
|
"display": "Received certificate of high school equivalency (finding)"
|
|
} ],
|
|
"text": "Received certificate of high school equivalency (finding)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1997-02-05T19:14:55+01:00",
|
|
"end": "1997-02-05T19:45:13+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"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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}, {
|
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"sequence": 6,
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"diagnosisSequence": [ 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://snomed.info/sct",
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"code": "741062008",
|
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"display": "Not in labor force (finding)"
|
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} ],
|
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"text": "Not in labor force (finding)"
|
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},
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"servicedPeriod": {
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"start": "1997-02-05T19:14:55+01:00",
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"end": "1997-02-05T19:45:13+01:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
|
|
"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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}, {
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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",
|
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"code": "171207006",
|
|
"display": "Depression screening (procedure)"
|
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} ],
|
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"text": "Depression screening (procedure)"
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},
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"start": "1997-02-05T19:14:55+01:00",
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"end": "1997-02-05T19:45:13+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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"display": "Off Campus-Outpatient Hospital"
|
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} ]
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},
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"net": {
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"value": 431.40,
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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_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": 86.28,
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}
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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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"amount": {
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"value": 345.12,
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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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"display": "Line Allowed Charge 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_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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"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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} ]
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},
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"code": "454711000124102",
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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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"value": 431.40,
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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_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": 86.28,
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}
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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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"amount": {
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"value": 345.12,
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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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"value": 431.40,
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}
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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": 431.40,
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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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"value": 0,
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}
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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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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} ]
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},
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"system": "http://loinc.org",
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|
"code": "55757-9",
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"display": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
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} ],
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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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_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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"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_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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}
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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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}
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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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} ]
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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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"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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"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_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": 10,
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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://snomed.info/sct",
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"code": "428211000124100",
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|
"display": "Assessment of substance use (procedure)"
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|
} ],
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"text": "Assessment of substance use (procedure)"
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|
},
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"start": "1997-02-05T19:14:55+01:00",
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"end": "1997-02-05T19:45:13+01:00"
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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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"value": 431.40,
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"currency": "USD"
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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": 86.28,
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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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"amount": {
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"value": 345.12,
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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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"value": 431.40,
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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": 431.40,
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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",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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|
},
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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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|
"category": {
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|
"coding": [ {
|
|
"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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|
}, {
|
|
"sequence": 11,
|
|
"category": {
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|
"coding": [ {
|
|
"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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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "763302001",
|
|
"display": "Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure)"
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|
} ],
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|
"text": "Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure)"
|
|
},
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|
"servicedPeriod": {
|
|
"start": "1997-02-05T19:14:55+01:00",
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|
"end": "1997-02-05T19:45:13+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",
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|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"currency": "USD"
|
|
},
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|
"adjudication": [ {
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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_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 86.28,
|
|
"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_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
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|
} ]
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|
},
|
|
"amount": {
|
|
"value": 345.12,
|
|
"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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},
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|
"amount": {
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|
"value": 431.40,
|
|
"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_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": 431.40,
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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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"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_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": 12,
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|
"informationSequence": [ 3 ],
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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",
|
|
"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": "72109-2",
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|
"display": "Alcohol Use Disorder Identification Test - Consumption [AUDIT-C]"
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|
} ],
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|
"text": "Alcohol Use Disorder Identification Test - Consumption [AUDIT-C]"
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|
},
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|
"servicedPeriod": {
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|
"start": "1997-02-05T19:14:55+01:00",
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|
"end": "1997-02-05T19:45:13+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": 74.58,
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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",
|
|
"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": {
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|
"value": 14.916,
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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_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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"amount": {
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"value": 74.58,
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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": 74.58,
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"currency": "USD"
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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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"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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|
"total": [ {
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"category": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
} ],
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|
"text": "Submitted Amount"
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},
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|
"amount": {
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|
"value": 1286.77,
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|
"currency": "USD"
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}
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} ],
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"payment": {
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"amount": {
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"value": 2419.784,
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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:1cb3609f-4284-eb93-1d3c-f46dd48e5b8d",
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"resource": {
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"resourceType": "Encounter",
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"id": "1cb3609f-4284-eb93-1d3c-f46dd48e5b8d",
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"meta": {
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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": "1cb3609f-4284-eb93-1d3c-f46dd48e5b8d"
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} ],
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"status": "finished",
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"class": {
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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",
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|
"code": "185349003",
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"display": "Encounter for check up"
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} ],
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"text": "Encounter for check up"
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} ],
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"subject": {
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"display": "Ms. Dorthy94 Kelly223 Klocko335"
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},
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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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} ],
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"text": "primary performer"
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} ],
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"period": {
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"start": "1997-02-19T22:21:03+01:00",
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"end": "1997-02-19T22:36:03+01:00"
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},
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"individual": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895",
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"display": "Dr. Patrina117 Strosin214"
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}
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} ],
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"period": {
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"start": "1997-02-19T22:21:03+01:00",
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},
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"system": "http://snomed.info/sct",
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"code": "58150001",
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"display": "Fracture of clavicle"
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} ]
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} ],
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"location": {
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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}
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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}
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},
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"method": "POST",
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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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"system": "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
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}
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"code": "professional"
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},
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},
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},
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"priority": {
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"system": "http://terminology.hl7.org/CodeSystem/processpriority",
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"code": "normal"
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} ]
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},
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"facility": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|5e756e0c-7c6b-37c0-8bd5-eebe86c41e5e",
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"unit": "%",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "%"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:1a9052d1-e491-2ff2-7942-77d73c3ffad8",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "1a9052d1-e491-2ff2-7942-77d73c3ffad8",
|
|
"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:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T19:14:55+01:00",
|
|
"issued": "1998-02-11T19:14:55.153+01:00",
|
|
"component": [ {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8462-4",
|
|
"display": "Diastolic Blood Pressure"
|
|
} ],
|
|
"text": "Diastolic Blood Pressure"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 86,
|
|
"unit": "mm[Hg]",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "mm[Hg]"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8480-6",
|
|
"display": "Systolic Blood Pressure"
|
|
} ],
|
|
"text": "Systolic Blood Pressure"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 119,
|
|
"unit": "mm[Hg]",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "mm[Hg]"
|
|
}
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:af52bb37-c82c-f313-d26e-5349b2db366a",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "af52bb37-c82c-f313-d26e-5349b2db366a",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-heart-rate" ]
|
|
},
|
|
"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": "8867-4",
|
|
"display": "Heart rate"
|
|
} ],
|
|
"text": "Heart rate"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T19:14:55+01:00",
|
|
"issued": "1998-02-11T19:14:55.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 66,
|
|
"unit": "/min",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/min"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:1f3deeee-a988-39f0-de9c-e6723421be08",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "1f3deeee-a988-39f0-de9c-e6723421be08",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-respiratory-rate" ]
|
|
},
|
|
"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": "9279-1",
|
|
"display": "Respiratory rate"
|
|
} ],
|
|
"text": "Respiratory rate"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T19:14:55+01:00",
|
|
"issued": "1998-02-11T19:14:55.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 16,
|
|
"unit": "/min",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/min"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:3bafb214-fa20-8bcb-b6aa-a28ccf09cb1f",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "3bafb214-fa20-8bcb-b6aa-a28ccf09cb1f",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "social-history",
|
|
"display": "Social history"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72166-2",
|
|
"display": "Tobacco smoking status"
|
|
} ],
|
|
"text": "Tobacco smoking status"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T19:14:55+01:00",
|
|
"issued": "1998-02-11T19:14:55.153+01:00",
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "266919005",
|
|
"display": "Never smoked tobacco (finding)"
|
|
} ],
|
|
"text": "Never smoked tobacco (finding)"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:085e0a8d-4426-5bcd-45f0-d39af270877a",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "085e0a8d-4426-5bcd-45f0-d39af270877a",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93025-5",
|
|
"display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
} ],
|
|
"text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T20:12:16+01:00",
|
|
"issued": "1998-02-11T20:12:16.153+01:00",
|
|
"component": [ {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76501-6",
|
|
"display": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
} ],
|
|
"text": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93026-3",
|
|
"display": "Do you feel physically and emotionally safe where you currently live?"
|
|
} ],
|
|
"text": "Do you feel physically and emotionally safe where you currently live?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA33-6",
|
|
"display": "Yes"
|
|
} ],
|
|
"text": "Yes"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93027-1",
|
|
"display": "Are you a refugee?"
|
|
} ],
|
|
"text": "Are you a refugee?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93028-9",
|
|
"display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
} ],
|
|
"text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93038-8",
|
|
"display": "Stress level"
|
|
} ],
|
|
"text": "Stress level"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6568-5",
|
|
"display": "Not at all"
|
|
} ],
|
|
"text": "Not at all"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93029-7",
|
|
"display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
} ],
|
|
"text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30132-7",
|
|
"display": "5 or more times a week"
|
|
} ],
|
|
"text": "5 or more times a week"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93030-5",
|
|
"display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
} ],
|
|
"text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93031-3",
|
|
"display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
} ],
|
|
"text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30122-8",
|
|
"display": "I choose not to answer this question"
|
|
} ],
|
|
"text": "I choose not to answer this question"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63586-2",
|
|
"display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
} ],
|
|
"text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 121160,
|
|
"unit": "/a",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/a"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76437-3",
|
|
"display": "Primary insurance"
|
|
} ],
|
|
"text": "Primary insurance"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6350-8",
|
|
"display": "Private insurance"
|
|
} ],
|
|
"text": "Private insurance"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "67875-5",
|
|
"display": "Employment status - current"
|
|
} ],
|
|
"text": "Employment status - current"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30138-4",
|
|
"display": "Part-time or temporary work"
|
|
} ],
|
|
"text": "Part-time or temporary work"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "82589-3",
|
|
"display": "Highest level of education"
|
|
} ],
|
|
"text": "Highest level of education"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30192-1",
|
|
"display": "High school diploma or GED"
|
|
} ],
|
|
"text": "High school diploma or GED"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56799-0",
|
|
"display": "Address"
|
|
} ],
|
|
"text": "Address"
|
|
},
|
|
"valueString": "1082 Weissnat Arcade"
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93033-9",
|
|
"display": "Are you worried about losing your housing?"
|
|
} ],
|
|
"text": "Are you worried about losing your housing?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "71802-3",
|
|
"display": "Housing status"
|
|
} ],
|
|
"text": "Housing status"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30189-7",
|
|
"display": "I have housing"
|
|
} ],
|
|
"text": "I have housing"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63512-8",
|
|
"display": "How many people are living or staying at this address?"
|
|
} ],
|
|
"text": "How many people are living or staying at this address?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 5,
|
|
"unit": "{#}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{#}"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "54899-0",
|
|
"display": "Preferred language"
|
|
} ],
|
|
"text": "Preferred language"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA43-5",
|
|
"display": "English"
|
|
} ],
|
|
"text": "English"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93034-7",
|
|
"display": "Have you been discharged from the armed forces of the United States?"
|
|
} ],
|
|
"text": "Have you been discharged from the armed forces of the United States?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93035-4",
|
|
"display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
} ],
|
|
"text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "32624-9",
|
|
"display": "Race"
|
|
} ],
|
|
"text": "Race"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA4457-3",
|
|
"display": "White"
|
|
} ],
|
|
"text": "White"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56051-6",
|
|
"display": "Do you consider yourself Hispanic/Latino?"
|
|
} ],
|
|
"text": "Do you consider yourself Hispanic/Latino?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:8291be2f-c30d-701a-93b8-58f935229769",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "8291be2f-c30d-701a-93b8-58f935229769",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "55758-7",
|
|
"display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
} ],
|
|
"text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T20:51:20+01:00",
|
|
"issued": "1998-02-11T20:51:20.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 1,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:9f83a064-a7dd-f8ee-6149-f3a605b5907b",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "9f83a064-a7dd-f8ee-6149-f3a605b5907b",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "82667-7",
|
|
"display": "Total score [DAST-10]"
|
|
} ],
|
|
"text": "Total score [DAST-10]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T21:26:43+01:00",
|
|
"issued": "1998-02-11T21:26:43.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 0,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:7fb43e61-2bdd-faf5-6ce5-9841efbde325",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "7fb43e61-2bdd-faf5-6ce5-9841efbde325",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "1998-02-11T19:14:55+01:00",
|
|
"end": "1998-02-11T19:29:55+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:6a900aff-d4ac-3940-b45d-3573a337c5fa",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "6a900aff-d4ac-3940-b45d-3573a337c5fa",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "710824005",
|
|
"display": "Assessment of health and social care needs (procedure)"
|
|
} ],
|
|
"text": "Assessment of health and social care needs (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "1998-02-11T19:14:55+01:00",
|
|
"end": "1998-02-11T20:12:16+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:5f87cd31-9680-52a5-dce1-dfda7f9e09cf",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "5f87cd31-9680-52a5-dce1-dfda7f9e09cf",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "171207006",
|
|
"display": "Depression screening (procedure)"
|
|
} ],
|
|
"text": "Depression screening (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "1998-02-11T20:12:16+01:00",
|
|
"end": "1998-02-11T20:25:43+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:c5109505-5cb1-517f-6b36-08b120e07089",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "c5109505-5cb1-517f-6b36-08b120e07089",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "454711000124102",
|
|
"display": "Depression screening using Patient Health Questionnaire Two-Item score (procedure)"
|
|
} ],
|
|
"text": "Depression screening using Patient Health Questionnaire Two-Item score (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "1998-02-11T20:25:43+01:00",
|
|
"end": "1998-02-11T20:51:20+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:6920e287-ff18-e322-2a1d-1d48156feb8d",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "6920e287-ff18-e322-2a1d-1d48156feb8d",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "428211000124100",
|
|
"display": "Assessment of substance use (procedure)"
|
|
} ],
|
|
"text": "Assessment of substance use (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "1998-02-11T20:51:20+01:00",
|
|
"end": "1998-02-11T21:04:29+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:fad4cbdf-42cc-e451-c6a2-df06277a5935",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "fad4cbdf-42cc-e451-c6a2-df06277a5935",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "713106006",
|
|
"display": "Screening for drug abuse (procedure)"
|
|
} ],
|
|
"text": "Screening for drug abuse (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "1998-02-11T21:04:29+01:00",
|
|
"end": "1998-02-11T21:26:43+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:9c78b78e-ee53-b805-ac1b-b41c53162c59",
|
|
"resource": {
|
|
"resourceType": "Immunization",
|
|
"id": "9c78b78e-ee53-b805-ac1b-b41c53162c59",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
|
|
},
|
|
"status": "completed",
|
|
"vaccineCode": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"patient": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"occurrenceDateTime": "1998-02-11T19:14:55+01:00",
|
|
"primarySource": true,
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
|
|
"display": "STANFORD HEALTH CARE"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Immunization"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:ff515614-5327-e4bb-fa77-cbc6433810be",
|
|
"resource": {
|
|
"resourceType": "DiagnosticReport",
|
|
"id": "ff515614-5327-e4bb-fa77-cbc6433810be",
|
|
"status": "final",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "55757-9",
|
|
"display": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
|
|
} ],
|
|
"text": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:c18c7145-70b8-cc14-42f6-ab08f82f61e6"
|
|
},
|
|
"effectiveDateTime": "1998-02-11T20:51:20+01:00",
|
|
"issued": "1998-02-11T20:51:20.153+01:00",
|
|
"result": [ {
|
|
"reference": "urn:uuid:8291be2f-c30d-701a-93b8-58f935229769",
|
|
"display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "DiagnosticReport"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:13222e30-08f8-372b-4cea-4638269f3131",
|
|
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"system": "http://snomed.info/sct",
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"code": "160904001",
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} ],
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"text": "Part-time employment (finding)"
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}
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}, {
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"sequence": 7,
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"system": "http://snomed.info/sct",
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"code": "171207006",
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} ],
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},
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"value": 431.40,
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}
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}, {
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"sequence": 8,
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"system": "http://snomed.info/sct",
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"code": "454711000124102",
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"display": "Depression screening using Patient Health Questionnaire Two-Item score (procedure)"
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} ],
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},
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"value": 431.40,
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}
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}, {
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"coding": [ {
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"system": "http://loinc.org",
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"code": "55757-9",
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"display": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
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} ],
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"text": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
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},
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"value": 74.58,
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}
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}
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"coding": [ {
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"system": "http://snomed.info/sct",
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"code": "713106006",
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} ],
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},
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"value": 431.40,
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}
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}, {
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"sequence": 12,
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"system": "http://loinc.org",
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"code": "82666-9",
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} ],
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},
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"value": 74.58,
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}
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} ],
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"value": 1102.12,
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}
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},
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"method": "POST",
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"url": "Claim"
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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|9999944199"
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},
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
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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": "Humana"
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},
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"beneficiary": {
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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},
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"payor": [ {
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"display": "Humana"
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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": "cedd3950-4a8b-b9bd-dacd-3e6d64034da0"
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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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"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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},
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},
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"created": "1998-02-11T20:12:16+01:00",
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"insurer": {
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"display": "Humana"
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},
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"provider": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
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},
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"referral": {
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"reference": "#referral"
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},
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"facility": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6700c70b-6981-31a9-b860-d57a4c9c8e17",
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"display": "STANFORD HEALTH CARE"
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},
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"claim": {
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"reference": "urn:uuid:cedd3950-4a8b-b9bd-dacd-3e6d64034da0"
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},
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"outcome": "complete",
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999944199"
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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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"code": "principal"
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} ]
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}, {
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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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}
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} ],
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},
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"productOrService": {
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"system": "http://snomed.info/sct",
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} ],
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"text": "General examination of patient (procedure)"
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},
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"start": "1998-02-11T19:14:55+01:00",
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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} ]
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"encounter": [ {
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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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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "140",
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|
} ],
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"text": "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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|
|
"value": 136.00,
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|
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|
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|
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|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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|
},
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|
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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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|
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|
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|
|
"display": "Medical care"
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|
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|
},
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|
"productOrService": {
|
|
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|
|
"system": "http://snomed.info/sct",
|
|
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|
|
"display": "Medication review due (situation)"
|
|
} ],
|
|
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|
|
},
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|
"servicedPeriod": {
|
|
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|
|
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|
|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
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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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|
|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
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|
"display": "Medical care"
|
|
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|
},
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|
"productOrService": {
|
|
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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": "1998-02-11T19:14:55+01:00",
|
|
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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",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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|
},
|
|
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|
"value": 397.92,
|
|
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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": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 79.584,
|
|
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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": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 318.336,
|
|
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|
|
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|
|
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|
"category": {
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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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|
"value": 397.92,
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|
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"category": {
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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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|
},
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|
"amount": {
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|
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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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|
} ]
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|
},
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|
"amount": {
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|
"value": 0,
|
|
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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_prcsg_ind_cd",
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|
"display": "Line Processing Indicator Code"
|
|
} ]
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|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 5,
|
|
"category": {
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|
"coding": [ {
|
|
"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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|
"productOrService": {
|
|
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|
"system": "http://snomed.info/sct",
|
|
"code": "710824005",
|
|
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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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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"display": "Off Campus-Outpatient Hospital"
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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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"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": 345.12,
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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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"amount": {
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"value": 431.40,
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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": 431.40,
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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": 6,
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"diagnosisSequence": [ 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://snomed.info/sct",
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"code": "160904001",
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"display": "Part-time employment (finding)"
|
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} ],
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"text": "Part-time employment (finding)"
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},
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"servicedPeriod": {
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"start": "1998-02-11T19:14:55+01:00",
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"end": "1998-02-11T20:12:16+01:00"
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},
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|
"locationCodeableConcept": {
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"coding": [ {
|
|
"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": 7,
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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://snomed.info/sct",
|
|
"code": "171207006",
|
|
"display": "Depression screening (procedure)"
|
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} ],
|
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"text": "Depression screening (procedure)"
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},
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"start": "1998-02-11T19:14:55+01:00",
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"end": "1998-02-11T20:12:16+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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"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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},
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"value": 431.40,
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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_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": 86.28,
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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_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": 345.12,
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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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"amount": {
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}
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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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"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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}
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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_prcsg_ind_cd",
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|
"display": "Line Processing Indicator Code"
|
|
} ]
|
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}
|
|
} ]
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}, {
|
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"sequence": 8,
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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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"system": "http://snomed.info/sct",
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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_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": 86.28,
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}
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}, {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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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": 345.12,
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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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"value": 431.40,
|
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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_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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|
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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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"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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|
"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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"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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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://loinc.org",
|
|
"code": "55757-9",
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|
"display": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
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|
} ],
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"text": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
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},
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"end": "1998-02-11T20:12:16+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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|
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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",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
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|
"amount": {
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|
"value": 14.916,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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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": 59.664,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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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",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
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|
},
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"amount": {
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"value": 74.58,
|
|
"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_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
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|
} ]
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},
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|
"amount": {
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|
"value": 74.58,
|
|
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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",
|
|
"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": 10,
|
|
"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": "428211000124100",
|
|
"display": "Assessment of substance use (procedure)"
|
|
} ],
|
|
"text": "Assessment of substance use (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "1998-02-11T19:14:55+01:00",
|
|
"end": "1998-02-11T20:12:16+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
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|
"value": 431.40,
|
|
"currency": "USD"
|
|
},
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|
"adjudication": [ {
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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_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 86.28,
|
|
"currency": "USD"
|
|
}
|
|
}, {
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|
"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": 345.12,
|
|
"currency": "USD"
|
|
}
|
|
}, {
|
|
"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": {
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|
"value": 431.40,
|
|
"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_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
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|
} ]
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|
},
|
|
"amount": {
|
|
"value": 431.40,
|
|
"currency": "USD"
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|
}
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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"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
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"sequence": 11,
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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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"system": "http://snomed.info/sct",
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"code": "713106006",
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} ],
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"text": "Screening for drug abuse (procedure)"
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},
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"start": "1998-02-11T19:14:55+01:00",
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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},
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"value": 431.40,
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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": 86.28,
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}
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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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": 345.12,
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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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"value": 431.40,
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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} ]
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},
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"value": 0,
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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_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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"display": "Line Beneficiary Coinsurance Amount"
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},
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"value": 14.916,
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},
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|
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|
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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"url": "DiagnosticReport"
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}, {
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"system": "http://loinc.org",
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"id": "a24fa471-c891-e845-fcf7-693871b52f9a",
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"contained": [ {
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"resourceType": "ServiceRequest",
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"id": "referral",
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"intent": "order",
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},
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"performer": [ {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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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": "Humana"
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},
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"beneficiary": {
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|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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},
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"payor": [ {
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|
"display": "Humana"
|
|
} ]
|
|
} ],
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|
"identifier": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/clm_id",
|
|
"value": "391e3ac8-4a80-7859-d2a9-ac013d35edfc"
|
|
}, {
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|
"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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|
"value": "99999999999"
|
|
} ],
|
|
"status": "active",
|
|
"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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"use": "claim",
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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},
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"end": "1999-11-06T00:45:26+01:00"
|
|
},
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|
"created": "1998-11-06T00:45:26+01:00",
|
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"insurer": {
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"display": "Humana"
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|
},
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"provider": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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|
},
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"referral": {
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|
"reference": "#referral"
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},
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"facility": {
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|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|5e756e0c-7c6b-37c0-8bd5-eebe86c41e5e",
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|
"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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},
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"claim": {
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|
"reference": "urn:uuid:391e3ac8-4a80-7859-d2a9-ac013d35edfc"
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},
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"outcome": "complete",
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"careTeam": [ {
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"provider": {
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|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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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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|
"insurance": [ {
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"focal": true,
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|
"coverage": {
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"reference": "#coverage",
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|
"display": "Humana"
|
|
}
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|
} ],
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|
"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"
|
|
} ]
|
|
},
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
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|
"code": "185347001",
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|
"display": "Encounter for problem (procedure)"
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|
} ],
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|
"text": "Encounter for problem (procedure)"
|
|
},
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|
"servicedPeriod": {
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|
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|
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|
|
},
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|
"locationCodeableConcept": {
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|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "21",
|
|
"display": "Inpatient Hospital"
|
|
} ]
|
|
},
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|
"encounter": [ {
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|
"reference": "urn:uuid:b16f73b2-7808-1ace-3230-0b4b2e8eb84c"
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|
} ]
|
|
}, {
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|
"sequence": 2,
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"category": {
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|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "52052004",
|
|
"display": "Rehabilitation therapy (regime/therapy)"
|
|
} ],
|
|
"text": "Rehabilitation therapy (regime/therapy)"
|
|
},
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|
"servicedPeriod": {
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|
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|
|
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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": "21",
|
|
"display": "Inpatient Hospital"
|
|
} ]
|
|
},
|
|
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|
|
"value": 431.40,
|
|
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|
|
},
|
|
"adjudication": [ {
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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_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 86.28,
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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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|
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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": {
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|
"value": 345.12,
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|
"currency": "USD"
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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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|
"amount": {
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|
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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",
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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": 431.40,
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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_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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"fullUrl": "urn:uuid:7e2a3a51-9eb0-7f40-21d4-e7af2de8acd2",
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"resourceType": "ExplanationOfBenefit",
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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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": "Humana"
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},
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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},
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"payor": [ {
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"display": "Humana"
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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": "3a9135fc-4dc1-9033-90ee-c9b47d105a3d"
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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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"system": "http://terminology.hl7.org/CodeSystem/claim-type",
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},
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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"claim": {
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"reference": "urn:uuid:3a9135fc-4dc1-9033-90ee-c9b47d105a3d"
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},
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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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"item": [ {
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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://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "21",
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"display": "Inpatient Hospital"
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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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"productOrService": {
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"code": "52052004",
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"text": "Rehabilitation therapy (regime/therapy)"
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},
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"start": "1998-12-06T00:45:26+01:00",
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"display": "Inpatient Hospital"
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},
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"value": 431.40,
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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": 86.28,
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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": "21",
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"display": "Inpatient Hospital"
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} ]
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}
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"display": "Line Beneficiary Coinsurance Amount"
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"display": "Line Provider Payment Amount"
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"display": "Line Submitted Charge 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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}
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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:df8058d1-1d4a-70ee-54d6-163efef67323",
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"resourceType": "ExplanationOfBenefit",
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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} ]
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}, {
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"resourceType": "Coverage",
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"id": "coverage",
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"text": "Humana"
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},
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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},
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"payor": [ {
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"display": "Humana"
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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": "2190cda8-eb5f-8030-173a-8dc44b9ebf12"
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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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"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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"created": "2000-02-19T21:03:37+01:00",
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"insurer": {
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"display": "Humana"
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},
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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},
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"reference": "#referral"
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},
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"facility": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|5e756e0c-7c6b-37c0-8bd5-eebe86c41e5e",
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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},
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"claim": {
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"reference": "urn:uuid:2190cda8-eb5f-8030-173a-8dc44b9ebf12"
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},
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"outcome": "complete",
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"sequence": 1,
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895"
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},
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"role": {
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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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"insurance": [ {
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"focal": true,
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"reference": "#coverage",
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} ],
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"code": "1",
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},
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"productOrService": {
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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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},
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"productOrService": {
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"system": "http://snomed.info/sct",
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"code": "52052004",
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} ],
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"value": 431.40,
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|
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},
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|
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|
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"system": "http://terminology.hl7.org/CodeSystem/medicationrequest-category",
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"display": "Community"
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|
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|
"coding": [ {
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|
"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
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|
"code": "313782",
|
|
"display": "Acetaminophen 325 MG Oral Tablet"
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|
} ],
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"text": "Acetaminophen 325 MG Oral Tablet"
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"requester": {
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} ]
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},
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} ],
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"code": "6690-2",
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|
} ],
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"code": "10*3/uL"
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},
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|
|
"fullUrl": "urn:uuid:8c8db17f-7709-4fda-e60f-c8ac57b237f9",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "8c8db17f-7709-4fda-e60f-c8ac57b237f9",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93025-5",
|
|
"display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
} ],
|
|
"text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:3002bdb5-873d-669d-5fe8-f05fe59f4aef"
|
|
},
|
|
"effectiveDateTime": "2000-05-03T21:11:07+02:00",
|
|
"issued": "2000-05-03T21:11:07.153+02:00",
|
|
"component": [ {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76501-6",
|
|
"display": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
} ],
|
|
"text": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93026-3",
|
|
"display": "Do you feel physically and emotionally safe where you currently live?"
|
|
} ],
|
|
"text": "Do you feel physically and emotionally safe where you currently live?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA33-6",
|
|
"display": "Yes"
|
|
} ],
|
|
"text": "Yes"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93027-1",
|
|
"display": "Are you a refugee?"
|
|
} ],
|
|
"text": "Are you a refugee?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93028-9",
|
|
"display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
} ],
|
|
"text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93038-8",
|
|
"display": "Stress level"
|
|
} ],
|
|
"text": "Stress level"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6568-5",
|
|
"display": "Not at all"
|
|
} ],
|
|
"text": "Not at all"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93029-7",
|
|
"display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
} ],
|
|
"text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30132-7",
|
|
"display": "5 or more times a week"
|
|
} ],
|
|
"text": "5 or more times a week"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93030-5",
|
|
"display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
} ],
|
|
"text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93031-3",
|
|
"display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
} ],
|
|
"text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30122-8",
|
|
"display": "I choose not to answer this question"
|
|
} ],
|
|
"text": "I choose not to answer this question"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63586-2",
|
|
"display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
} ],
|
|
"text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 121160,
|
|
"unit": "/a",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/a"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76437-3",
|
|
"display": "Primary insurance"
|
|
} ],
|
|
"text": "Primary insurance"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6350-8",
|
|
"display": "Private insurance"
|
|
} ],
|
|
"text": "Private insurance"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "67875-5",
|
|
"display": "Employment status - current"
|
|
} ],
|
|
"text": "Employment status - current"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30136-8",
|
|
"display": "Full-time work"
|
|
} ],
|
|
"text": "Full-time work"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "82589-3",
|
|
"display": "Highest level of education"
|
|
} ],
|
|
"text": "Highest level of education"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30192-1",
|
|
"display": "High school diploma or GED"
|
|
} ],
|
|
"text": "High school diploma or GED"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56799-0",
|
|
"display": "Address"
|
|
} ],
|
|
"text": "Address"
|
|
},
|
|
"valueString": "1082 Weissnat Arcade"
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93033-9",
|
|
"display": "Are you worried about losing your housing?"
|
|
} ],
|
|
"text": "Are you worried about losing your housing?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "71802-3",
|
|
"display": "Housing status"
|
|
} ],
|
|
"text": "Housing status"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30189-7",
|
|
"display": "I have housing"
|
|
} ],
|
|
"text": "I have housing"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63512-8",
|
|
"display": "How many people are living or staying at this address?"
|
|
} ],
|
|
"text": "How many people are living or staying at this address?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 5,
|
|
"unit": "{#}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{#}"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "54899-0",
|
|
"display": "Preferred language"
|
|
} ],
|
|
"text": "Preferred language"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA43-5",
|
|
"display": "English"
|
|
} ],
|
|
"text": "English"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93034-7",
|
|
"display": "Have you been discharged from the armed forces of the United States?"
|
|
} ],
|
|
"text": "Have you been discharged from the armed forces of the United States?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93035-4",
|
|
"display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
} ],
|
|
"text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "32624-9",
|
|
"display": "Race"
|
|
} ],
|
|
"text": "Race"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA4457-3",
|
|
"display": "White"
|
|
} ],
|
|
"text": "White"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56051-6",
|
|
"display": "Do you consider yourself Hispanic/Latino?"
|
|
} ],
|
|
"text": "Do you consider yourself Hispanic/Latino?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:a6b221ea-05e4-62e2-aa73-563bdd82faad",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "a6b221ea-05e4-62e2-aa73-563bdd82faad",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "70274-6",
|
|
"display": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
|
|
} ],
|
|
"text": "Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:3002bdb5-873d-669d-5fe8-f05fe59f4aef"
|
|
},
|
|
"effectiveDateTime": "2000-05-03T21:26:43+02:00",
|
|
"issued": "2000-05-03T21:26:43.153+02:00",
|
|
"valueQuantity": {
|
|
"value": 9,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:0f9534ef-66a0-21c8-5a67-7bcaf4cac5f2",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "0f9534ef-66a0-21c8-5a67-7bcaf4cac5f2",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "55758-7",
|
|
"display": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
} ],
|
|
"text": "Patient Health Questionnaire 2 item (PHQ-2) total score [Reported]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:3002bdb5-873d-669d-5fe8-f05fe59f4aef"
|
|
},
|
|
"effectiveDateTime": "2000-05-03T22:08:28+02:00",
|
|
"issued": "2000-05-03T22:08:28.153+02:00",
|
|
"valueQuantity": {
|
|
"value": 1,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:a3bc96f0-ee56-54e4-b8a3-e97a291c5cd6",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "a3bc96f0-ee56-54e4-b8a3-e97a291c5cd6",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:3002bdb5-873d-669d-5fe8-f05fe59f4aef"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "2000-05-03T20:14:55+02:00",
|
|
"end": "2000-05-03T20:29:55+02:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|1be621ef-e6e5-3cc1-aa08-29bd4a485f6b",
|
|
"display": "PATRIOT URGENT CARE PROFESSIONALS PC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
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"sequence": 8,
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"productOrService": {
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"system": "http://snomed.info/sct",
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"code": "710824005",
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} ],
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},
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"value": 431.40,
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}
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}, {
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"sequence": 9,
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"coding": [ {
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"system": "http://snomed.info/sct",
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"code": "160903007",
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"display": "Full-time employment (finding)"
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} ],
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"text": "Full-time employment (finding)"
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}
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}, {
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"system": "http://snomed.info/sct",
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"code": "710841007",
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"display": "Assessment of anxiety (procedure)"
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} ],
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"value": 431.40,
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"system": "http://loinc.org",
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"code": "69737-5",
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} ],
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"code": "454711000124102",
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"sequence": 14,
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"coding": [ {
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"system": "http://loinc.org",
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"code": "55757-9",
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} ],
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"value": 74.58,
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}
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},
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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:cca1d672-21c4-4162-0117-2c3289a43d65",
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"resource": {
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"resourceType": "ServiceRequest",
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"id": "referral",
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"status": "completed",
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"subject": {
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
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},
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999939892"
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},
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"performer": [ {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999939892"
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} ]
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}, {
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"resourceType": "Coverage",
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"id": "coverage",
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"type": {
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"text": "Humana"
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},
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},
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"payor": [ {
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"display": "Humana"
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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": "aae2d4ad-2498-31c5-3ed4-aab43c163631"
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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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"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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},
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},
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"created": "2000-05-03T21:11:07+02:00",
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"insurer": {
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"display": "Humana"
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},
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"provider": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999939892"
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},
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"referral": {
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"reference": "#referral"
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},
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"facility": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|1be621ef-e6e5-3cc1-aa08-29bd4a485f6b",
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"display": "PATRIOT URGENT CARE PROFESSIONALS PC"
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},
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"claim": {
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"reference": "urn:uuid:aae2d4ad-2498-31c5-3ed4-aab43c163631"
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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|9999939892"
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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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},
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"code": "principal"
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} ]
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} ]
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}, {
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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": {
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} ],
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},
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"productOrService": {
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"system": "http://snomed.info/sct",
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"code": "702927004",
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} ],
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"text": "Urgent care clinic (environment)"
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},
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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},
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"encounter": [ {
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"reference": "urn:uuid:3002bdb5-873d-669d-5fe8-f05fe59f4aef"
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} ]
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} ]
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},
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"productOrService": {
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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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|
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|
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|
} ],
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|
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|
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"display": "Line Beneficiary Coinsurance Amount"
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|
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"display": "Line Provider Payment Amount"
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|
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"display": "Line Submitted Charge Amount"
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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 Allowed Charge Amount"
|
|
} ]
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|
},
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"amount": {
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|
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|
|
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|
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|
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|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
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|
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|
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|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 4,
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|
"informationSequence": [ 3 ],
|
|
"category": {
|
|
"coding": [ {
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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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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "43",
|
|
"display": "Hep B, adult"
|
|
} ],
|
|
"text": "Hep B, adult"
|
|
},
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|
"servicedPeriod": {
|
|
"start": "2000-05-03T20:14:55+02:00",
|
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"end": "2000-05-03T21:11:07+02:00"
|
|
},
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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": "20",
|
|
"display": "Urgent Care Facility"
|
|
} ]
|
|
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"net": {
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"value": 136.00,
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"currency": "USD"
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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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} ]
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"amount": {
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"value": 27.200000000000003,
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"display": "Line Provider Payment Amount"
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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",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"value": 136.00,
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}
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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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"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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"value": 0,
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}
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}, {
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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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"display": "Medical care"
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} ]
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},
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"code": "314529007",
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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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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "20",
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"display": "Urgent Care Facility"
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} ]
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}
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}, {
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"display": "Medical care"
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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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},
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"display": "Urgent Care Facility"
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} ]
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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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}
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"display": "Line Provider Payment Amount"
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} ]
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},
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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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}
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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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}
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}, {
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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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"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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"display": "Medical care"
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} ]
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},
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"system": "http://loinc.org",
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"code": "58410-2",
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"display": "CBC panel - Blood by Automated count"
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} ],
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},
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},
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"display": "Urgent Care Facility"
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} ]
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},
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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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}
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}, {
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"display": "Line Provider Payment Amount"
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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": "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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"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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"system": "http://snomed.info/sct",
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|
"code": "710824005",
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|
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|
} ],
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|
},
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"end": "2000-05-03T21:11:07+02:00"
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "20",
|
|
"display": "Urgent Care Facility"
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|
} ]
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},
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"value": 431.40,
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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_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": 86.28,
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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_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": 345.12,
|
|
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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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}
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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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|
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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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"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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|
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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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|
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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://snomed.info/sct",
|
|
"code": "160903007",
|
|
"display": "Full-time employment (finding)"
|
|
} ],
|
|
"text": "Full-time employment (finding)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2000-05-03T20:14:55+02:00",
|
|
"end": "2000-05-03T21:11:07+02:00"
|
|
},
|
|
"locationCodeableConcept": {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "20",
|
|
"display": "Urgent Care Facility"
|
|
} ]
|
|
}
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|
}, {
|
|
"sequence": 10,
|
|
"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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|
"productOrService": {
|
|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "710841007",
|
|
"display": "Assessment of anxiety (procedure)"
|
|
} ],
|
|
"text": "Assessment of anxiety (procedure)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2000-05-03T20:14:55+02:00",
|
|
"end": "2000-05-03T21:11:07+02:00"
|
|
},
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|
"locationCodeableConcept": {
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "20",
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|
"display": "Urgent Care Facility"
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|
} ]
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|
},
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|
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|
"value": 431.40,
|
|
"currency": "USD"
|
|
},
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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_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": 86.28,
|
|
"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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|
},
|
|
"amount": {
|
|
"value": 345.12,
|
|
"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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|
},
|
|
"amount": {
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|
"value": 431.40,
|
|
"currency": "USD"
|
|
}
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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_alowd_chrg_amt",
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|
"display": "Line Allowed Charge Amount"
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|
} ]
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|
},
|
|
"amount": {
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|
"value": 431.40,
|
|
"currency": "USD"
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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,
|
|
"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",
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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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|
} ]
|
|
}, {
|
|
"sequence": 11,
|
|
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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",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "69737-5",
|
|
"display": "Generalized anxiety disorder 7 item (GAD-7)"
|
|
} ],
|
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"text": "Generalized anxiety disorder 7 item (GAD-7)"
|
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},
|
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"servicedPeriod": {
|
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"start": "2000-05-03T20:14:55+02:00",
|
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"end": "2000-05-03T21:11:07+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": "20",
|
|
"display": "Urgent Care Facility"
|
|
} ]
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},
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"net": {
|
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"value": 74.58,
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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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"amount": {
|
|
"value": 14.916,
|
|
"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": {
|
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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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"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": 74.58,
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"currency": "USD"
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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_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": 74.58,
|
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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_bene_ptb_ddctbl_amt",
|
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"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
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}
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}, {
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"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": 12,
|
|
"category": {
|
|
"coding": [ {
|
|
"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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},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "171207006",
|
|
"display": "Depression screening (procedure)"
|
|
} ],
|
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"text": "Depression screening (procedure)"
|
|
},
|
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"servicedPeriod": {
|
|
"start": "2000-05-03T20:14:55+02:00",
|
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"end": "2000-05-03T21:11:07+02:00"
|
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},
|
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"locationCodeableConcept": {
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"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "20",
|
|
"display": "Urgent Care Facility"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
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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",
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"display": "Line Beneficiary Coinsurance Amount"
|
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} ]
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},
|
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"amount": {
|
|
"value": 86.28,
|
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"currency": "USD"
|
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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"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 345.12,
|
|
"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_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": 431.40,
|
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"currency": "USD"
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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_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": 431.40,
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"currency": "USD"
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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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|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
|
}
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|
}, {
|
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"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": 13,
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
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},
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"productOrService": {
|
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"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "454711000124102",
|
|
"display": "Depression screening using Patient Health Questionnaire Two-Item score (procedure)"
|
|
} ],
|
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"text": "Depression screening using Patient Health Questionnaire Two-Item score (procedure)"
|
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},
|
|
"servicedPeriod": {
|
|
"start": "2000-05-03T20:14:55+02:00",
|
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"end": "2000-05-03T21:11:07+02:00"
|
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},
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"locationCodeableConcept": {
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|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "20",
|
|
"display": "Urgent Care Facility"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
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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_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 86.28,
|
|
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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_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 345.12,
|
|
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|
|
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|
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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": 431.40,
|
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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_alowd_chrg_amt",
|
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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_bene_ptb_ddctbl_amt",
|
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|
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"amount": {
|
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"value": 0,
|
|
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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",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 14,
|
|
"informationSequence": [ 6 ],
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|
"category": {
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"coding": [ {
|
|
"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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|
"productOrService": {
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"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "55757-9",
|
|
"display": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
|
|
} ],
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"text": "Patient Health Questionnaire 2 item (PHQ-2) [Reported]"
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},
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"start": "2000-05-03T20:14:55+02:00",
|
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"end": "2000-05-03T21:11:07+02:00"
|
|
},
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"locationCodeableConcept": {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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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_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
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"amount": {
|
|
"value": 14.916,
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|
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"display": "Line Provider Payment Amount"
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} ]
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|
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"display": "Line Allowed Charge Amount"
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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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|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
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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",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
} ],
|
|
"total": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
} ],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 1730.59,
|
|
"currency": "USD"
|
|
}
|
|
} ],
|
|
"payment": {
|
|
"amount": {
|
|
"value": 2425.096,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:5c3ac174-408f-10c1-820b-a5166dff59a8",
|
|
"resource": {
|
|
"resourceType": "Encounter",
|
|
"id": "5c3ac174-408f-10c1-820b-a5166dff59a8",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
|
|
},
|
|
"identifier": [ {
|
|
"use": "official",
|
|
"system": "https://github.com/synthetichealth/synthea",
|
|
"value": "5c3ac174-408f-10c1-820b-a5166dff59a8"
|
|
} ],
|
|
"status": "finished",
|
|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
|
|
"code": "AMB"
|
|
},
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "185349003",
|
|
"display": "Encounter for check up (procedure)"
|
|
} ],
|
|
"text": "Encounter for check up (procedure)"
|
|
} ],
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
|
|
"display": "Ms. Dorthy94 Kelly223 Klocko335"
|
|
},
|
|
"participant": [ {
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
|
|
"code": "PPRF",
|
|
"display": "primary performer"
|
|
} ],
|
|
"text": "primary performer"
|
|
} ],
|
|
"period": {
|
|
"start": "2000-05-10T20:14:55+02:00",
|
|
"end": "2000-05-10T20:29:55+02:00"
|
|
},
|
|
"individual": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999995092",
|
|
"display": "Dr. Darnell564 Leannon79"
|
|
}
|
|
} ],
|
|
"period": {
|
|
"start": "2000-05-10T20:14:55+02:00",
|
|
"end": "2000-05-10T20:29:55+02:00"
|
|
},
|
|
"location": [ {
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|d11f97b5-721f-3bcd-8c00-973ba1f8f1b3",
|
|
"display": "CHILDREN'S HOSPITAL CORPORATION"
|
|
}
|
|
} ],
|
|
"serviceProvider": {
|
|
"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|a2cc09de-c1e2-3126-8c09-d49f95225281",
|
|
"display": "CHILDREN'S HOSPITAL CORPORATION"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Encounter"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:bbcb1a2b-71ef-168c-86ba-2dbfae7942e8",
|
|
"resource": {
|
|
"resourceType": "Condition",
|
|
"id": "bbcb1a2b-71ef-168c-86ba-2dbfae7942e8",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis" ]
|
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} ]
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},
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} ],
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}
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"value": 378.77,
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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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"resourceType": "Coverage",
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},
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"display": "Humana"
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} ]
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} ],
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"identifier": [ {
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"value": "981c7389-54f3-d9bd-1ab1-a06a7a89e909"
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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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"code": "professional"
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},
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999995092"
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},
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"referral": {
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"reference": "#referral"
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},
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|d11f97b5-721f-3bcd-8c00-973ba1f8f1b3",
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"display": "CHILDREN'S HOSPITAL CORPORATION"
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},
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"reference": "urn:uuid:981c7389-54f3-d9bd-1ab1-a06a7a89e909"
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},
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"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
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"code": "primary",
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"code": "principal"
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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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"display": "Inpatient Hospital"
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|
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"code": "430193006",
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|
} ],
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"display": "Line Beneficiary Coinsurance Amount"
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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": 303.016,
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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": 378.77,
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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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}
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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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}
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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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"amount": {
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"value": 736.32,
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}
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} ],
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"amount": {
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"value": 520.616,
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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:0b0c983f-68b7-e364-dbbb-fce78da958ce",
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"meta": {
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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": "0b0c983f-68b7-e364-dbbb-fce78da958ce"
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} ],
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"status": "finished",
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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",
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"code": "424441002",
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|
"display": "Prenatal initial visit"
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|
} ],
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"text": "Prenatal initial visit"
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} ],
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"display": "Ms. Dorthy94 Kelly223 Klocko335"
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"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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"code": "PPRF",
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},
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"individual": {
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},
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"reasonCode": [ {
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"system": "http://snomed.info/sct",
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"code": "72892002",
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} ],
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"location": {
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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} ],
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|
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|
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|
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|
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"focal": true,
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"coverage": {
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|
"reference": "#coverage",
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|
"display": "Humana"
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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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|
"system": "http://snomed.info/sct",
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|
"code": "424441002",
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|
"display": "Prenatal initial visit"
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|
} ],
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|
"text": "Prenatal initial visit"
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|
},
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|
"start": "2000-07-19T20:14:55+02:00",
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"end": "2000-07-19T20:29:55+02:00"
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "21",
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} ]
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},
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"encounter": [ {
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"reference": "urn:uuid:0b0c983f-68b7-e364-dbbb-fce78da958ce"
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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": "72892002",
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|
"display": "Normal pregnancy"
|
|
} ],
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|
"text": "Normal pregnancy"
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|
},
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|
"servicedPeriod": {
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|
"start": "2000-07-19T20:14:55+02:00",
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|
"end": "2000-07-19T20:29:55+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": "21",
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"display": "Inpatient Hospital"
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} ]
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}
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}, {
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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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} ]
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},
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"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "252160004",
|
|
"display": "Standard pregnancy test"
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|
} ],
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|
"text": "Standard pregnancy test"
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|
},
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|
"servicedPeriod": {
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|
"start": "2000-07-19T20:14:55+02:00",
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|
"end": "2000-07-19T20:29:55+02:00"
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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": "21",
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"display": "Inpatient Hospital"
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} ]
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},
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"net": {
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"value": 6580.91,
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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_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": 1316.182,
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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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"amount": {
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"value": 5264.728,
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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": 6580.91,
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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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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|
"amount": {
|
|
"value": 0,
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|
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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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|
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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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": "169230002",
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|
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|
} ],
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|
"text": "Ultrasound scan for fetal viability"
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|
},
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|
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"start": "2000-07-19T20:14:55+02:00",
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"value": 9146.98,
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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": 1829.396,
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}
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},
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|
"amount": {
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|
"value": 7317.584,
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"display": "Line Submitted Charge Amount"
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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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"amount": {
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"value": 0,
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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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|
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|
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|
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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": "19169002",
|
|
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|
|
} ],
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|
"text": "Miscarriage in first trimester"
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|
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|
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|
|
"start": "2000-07-19T20:14:55+02:00",
|
|
"end": "2000-07-19T20:29:55+02:00"
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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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|
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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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|
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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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|
"text": "Complete miscarriage (disorder)"
|
|
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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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"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:8225eb94-78a6-aff1-8bd4-815529b31ea0",
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},
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"code": "AMB"
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|
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|
"type": [ {
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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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|
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|
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|
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|
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|
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|
},
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|
"individual": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999985895",
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|
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|
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},
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|
"reasonCode": [ {
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"coding": [ {
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|
"system": "http://snomed.info/sct",
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|
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|
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|
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|
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"location": {
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|
"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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|
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|
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|
"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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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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|
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|
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|
"reasonReference": [ {
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|
"reference": "urn:uuid:58a5d531-0a44-e3b9-d1bb-a7827f30aae6",
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|
"display": "Normal pregnancy"
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|
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|
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|
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|
"method": "POST",
|
|
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|
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|
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|
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|
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|
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|
"id": "813b1e5c-aeab-20a2-4631-251283ff2336",
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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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|
"system": "http://snomed.info/sct",
|
|
"code": "171207006",
|
|
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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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"end": "2000-07-30T20:29:55+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": "21",
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|
"display": "Inpatient Hospital"
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|
} ]
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},
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"encounter": [ {
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|
"reference": "urn:uuid:8225eb94-78a6-aff1-8bd4-815529b31ea0"
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|
} ]
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}, {
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"sequence": 2,
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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": "5880005",
|
|
"display": "Physical examination procedure (procedure)"
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|
} ],
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"text": "Physical examination procedure (procedure)"
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|
},
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"servicedPeriod": {
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|
"start": "2000-07-30T20:14:55+02:00",
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"end": "2000-07-30T20:29:55+02:00"
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},
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"locationCodeableConcept": {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "21",
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|
"display": "Inpatient Hospital"
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|
} ]
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},
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"net": {
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|
"value": 431.40,
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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_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": 86.28,
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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": 345.12,
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}
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"display": "Line Submitted Charge Amount"
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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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"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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"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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"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",
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"code": "171207006",
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|
"display": "Depression screening"
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} ],
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"text": "Depression screening"
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},
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"start": "2000-07-30T20:14:55+02:00",
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"end": "2000-07-30T20:29:55+02:00"
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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": "21",
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"display": "Inpatient Hospital"
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} ]
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},
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"value": 431.40,
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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_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": 86.28,
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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": 345.12,
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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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"request": {
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"method": "POST",
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},
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"identifier": [ {
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"code": "AMB"
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},
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"type": [ {
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"system": "http://snomed.info/sct",
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|
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|
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} ],
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"subject": {
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"display": "Ms. Dorthy94 Kelly223 Klocko335"
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"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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},
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"individual": {
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},
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"system": "http://snomed.info/sct",
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|
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"location": {
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"display": "CHILDREN'S HOSPITAL CORPORATION"
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"serviceProvider": {
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"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
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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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|
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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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|
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
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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": "72514-3",
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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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"code": "39156-5",
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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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},
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}
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},
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},
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"code": "social-history",
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} ]
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} ],
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"code": "72166-2",
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|
|
} ],
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "266919005",
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|
} ],
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}
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},
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"code": "survey",
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} ],
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"code": {
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"coding": [ {
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"code": "93025-5",
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} ],
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"effectiveDateTime": "2001-01-03T19:51:38+01:00",
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|
"system": "http://loinc.org",
|
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"code": "76501-6",
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|
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|
} ],
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},
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"system": "http://loinc.org",
|
|
"code": "LA32-8",
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"display": "No"
|
|
} ],
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"text": "No"
|
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}
|
|
}, {
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|
"code": {
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|
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"system": "http://loinc.org",
|
|
"code": "93026-3",
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"display": "Do you feel physically and emotionally safe where you currently live?"
|
|
} ],
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|
"text": "Do you feel physically and emotionally safe where you currently live?"
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|
},
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"text": "Yes"
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|
"code": "93027-1",
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"display": "Are you a refugee?"
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|
} ],
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"text": "Are you a refugee?"
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} ],
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|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93038-8",
|
|
"display": "Stress level"
|
|
} ],
|
|
"text": "Stress level"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30122-8",
|
|
"display": "I choose not to answer this question"
|
|
} ],
|
|
"text": "I choose not to answer this question"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93029-7",
|
|
"display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
} ],
|
|
"text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30130-1",
|
|
"display": "1 or 2 times a week"
|
|
} ],
|
|
"text": "1 or 2 times a week"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93030-5",
|
|
"display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
} ],
|
|
"text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93031-3",
|
|
"display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
} ],
|
|
"text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30122-8",
|
|
"display": "I choose not to answer this question"
|
|
} ],
|
|
"text": "I choose not to answer this question"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63586-2",
|
|
"display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
} ],
|
|
"text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 121160,
|
|
"unit": "/a",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/a"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76437-3",
|
|
"display": "Primary insurance"
|
|
} ],
|
|
"text": "Primary insurance"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6350-8",
|
|
"display": "Private insurance"
|
|
} ],
|
|
"text": "Private insurance"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "67875-5",
|
|
"display": "Employment status - current"
|
|
} ],
|
|
"text": "Employment status - current"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA17956-6",
|
|
"display": "Unemployed"
|
|
} ],
|
|
"text": "Unemployed"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "82589-3",
|
|
"display": "Highest level of education"
|
|
} ],
|
|
"text": "Highest level of education"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30192-1",
|
|
"display": "High school diploma or GED"
|
|
} ],
|
|
"text": "High school diploma or GED"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56799-0",
|
|
"display": "Address"
|
|
} ],
|
|
"text": "Address"
|
|
},
|
|
"valueString": "1082 Weissnat Arcade"
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93033-9",
|
|
"display": "Are you worried about losing your housing?"
|
|
} ],
|
|
"text": "Are you worried about losing your housing?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "71802-3",
|
|
"display": "Housing status"
|
|
} ],
|
|
"text": "Housing status"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30189-7",
|
|
"display": "I have housing"
|
|
} ],
|
|
"text": "I have housing"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63512-8",
|
|
"display": "How many people are living or staying at this address?"
|
|
} ],
|
|
"text": "How many people are living or staying at this address?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 5,
|
|
"unit": "{#}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{#}"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "54899-0",
|
|
"display": "Preferred language"
|
|
} ],
|
|
"text": "Preferred language"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA43-5",
|
|
"display": "English"
|
|
} ],
|
|
"text": "English"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93034-7",
|
|
"display": "Have you been discharged from the armed forces of the United States?"
|
|
} ],
|
|
"text": "Have you been discharged from the armed forces of the United States?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93035-4",
|
|
"display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
} ],
|
|
"text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "32624-9",
|
|
"display": "Race"
|
|
} ],
|
|
"text": "Race"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA4457-3",
|
|
"display": "White"
|
|
} ],
|
|
"text": "White"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56051-6",
|
|
"display": "Do you consider yourself Hispanic/Latino?"
|
|
} ],
|
|
"text": "Do you consider yourself Hispanic/Latino?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:0c20d758-19e1-e568-5fa7-3eb29dd8ce86",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "0c20d758-19e1-e568-5fa7-3eb29dd8ce86",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76504-0",
|
|
"display": "Total score [HARK]"
|
|
} ],
|
|
"text": "Total score [HARK]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a3e211b7-e758-c3f6-b7d5-8c5bb2f7576d"
|
|
},
|
|
"effectiveDateTime": "2001-01-03T20:34:17+01:00",
|
|
"issued": "2001-01-03T20:34:17.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 0,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:c88e648f-329b-4c27-384c-908a0909a237",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "c88e648f-329b-4c27-384c-908a0909a237",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a3e211b7-e758-c3f6-b7d5-8c5bb2f7576d"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "2001-01-03T19:14:55+01:00",
|
|
"end": "2001-01-03T19:29:55+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|1be621ef-e6e5-3cc1-aa08-29bd4a485f6b",
|
|
"display": "PATRIOT URGENT CARE PROFESSIONALS PC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:62b1ad27-27af-83a8-1094-d071d78195a0",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "62b1ad27-27af-83a8-1094-d071d78195a0",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "710824005",
|
|
"display": "Assessment of health and social care needs (procedure)"
|
|
} ],
|
|
"text": "Assessment of health and social care needs (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a3e211b7-e758-c3f6-b7d5-8c5bb2f7576d"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "2001-01-03T19:14:55+01:00",
|
|
"end": "2001-01-03T19:51:38+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|1be621ef-e6e5-3cc1-aa08-29bd4a485f6b",
|
|
"display": "PATRIOT URGENT CARE PROFESSIONALS PC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:9798a532-e7aa-08da-0854-67d380196049",
|
|
"resource": {
|
|
"resourceType": "Procedure",
|
|
"id": "9798a532-e7aa-08da-0854-67d380196049",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure" ]
|
|
},
|
|
"status": "completed",
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "866148006",
|
|
"display": "Screening for domestic abuse (procedure)"
|
|
} ],
|
|
"text": "Screening for domestic abuse (procedure)"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a3e211b7-e758-c3f6-b7d5-8c5bb2f7576d"
|
|
},
|
|
"performedPeriod": {
|
|
"start": "2001-01-03T19:51:38+01:00",
|
|
"end": "2001-01-03T20:34:17+01:00"
|
|
},
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|1be621ef-e6e5-3cc1-aa08-29bd4a485f6b",
|
|
"display": "PATRIOT URGENT CARE PROFESSIONALS PC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Procedure"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:e258a8c8-7b44-b416-f69b-7472428ef5b6",
|
|
"resource": {
|
|
"resourceType": "Immunization",
|
|
"id": "e258a8c8-7b44-b416-f69b-7472428ef5b6",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
|
|
},
|
|
"status": "completed",
|
|
"vaccineCode": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "140",
|
|
"display": "Influenza, seasonal, injectable, preservative free"
|
|
} ],
|
|
"text": "Influenza, seasonal, injectable, preservative free"
|
|
},
|
|
"patient": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a3e211b7-e758-c3f6-b7d5-8c5bb2f7576d"
|
|
},
|
|
"occurrenceDateTime": "2001-01-03T19:14:55+01:00",
|
|
"primarySource": true,
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|1be621ef-e6e5-3cc1-aa08-29bd4a485f6b",
|
|
"display": "PATRIOT URGENT CARE PROFESSIONALS PC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Immunization"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:760048c4-2121-006d-51db-c4d08c4b1d55",
|
|
"resource": {
|
|
"resourceType": "Immunization",
|
|
"id": "760048c4-2121-006d-51db-c4d08c4b1d55",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
|
|
},
|
|
"status": "completed",
|
|
"vaccineCode": {
|
|
"coding": [ {
|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "43",
|
|
"display": "Hep B, adult"
|
|
} ],
|
|
"text": "Hep B, adult"
|
|
},
|
|
"patient": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a3e211b7-e758-c3f6-b7d5-8c5bb2f7576d"
|
|
},
|
|
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"system": "http://snomed.info/sct",
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"code": "185349003",
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"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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"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": "9279-1",
|
|
"display": "Respiratory rate"
|
|
} ],
|
|
"text": "Respiratory rate"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a35bb239-f8ac-7bff-b88b-f214190a5f3a"
|
|
},
|
|
"effectiveDateTime": "2001-02-14T19:14:55+01:00",
|
|
"issued": "2001-02-14T19:14:55.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 13,
|
|
"unit": "/min",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/min"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:d0298a4c-0ede-b732-07f9-100616fff3eb",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "d0298a4c-0ede-b732-07f9-100616fff3eb",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-social-history" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "social-history",
|
|
"display": "Social history"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72166-2",
|
|
"display": "Tobacco smoking status"
|
|
} ],
|
|
"text": "Tobacco smoking status"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a35bb239-f8ac-7bff-b88b-f214190a5f3a"
|
|
},
|
|
"effectiveDateTime": "2001-02-14T19:14:55+01:00",
|
|
"issued": "2001-02-14T19:14:55.153+01:00",
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "266919005",
|
|
"display": "Never smoked tobacco (finding)"
|
|
} ],
|
|
"text": "Never smoked tobacco (finding)"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:a258af12-a86f-b338-7517-04eefce813f8",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "a258af12-a86f-b338-7517-04eefce813f8",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93025-5",
|
|
"display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
} ],
|
|
"text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a35bb239-f8ac-7bff-b88b-f214190a5f3a"
|
|
},
|
|
"effectiveDateTime": "2001-02-14T19:47:13+01:00",
|
|
"issued": "2001-02-14T19:47:13.153+01:00",
|
|
"component": [ {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76501-6",
|
|
"display": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
} ],
|
|
"text": "Within the last year, have you been afraid of your partner or ex-partner?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93026-3",
|
|
"display": "Do you feel physically and emotionally safe where you currently live?"
|
|
} ],
|
|
"text": "Do you feel physically and emotionally safe where you currently live?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA33-6",
|
|
"display": "Yes"
|
|
} ],
|
|
"text": "Yes"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93027-1",
|
|
"display": "Are you a refugee?"
|
|
} ],
|
|
"text": "Are you a refugee?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93028-9",
|
|
"display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
} ],
|
|
"text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93038-8",
|
|
"display": "Stress level"
|
|
} ],
|
|
"text": "Stress level"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6568-5",
|
|
"display": "Not at all"
|
|
} ],
|
|
"text": "Not at all"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93029-7",
|
|
"display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
} ],
|
|
"text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30132-7",
|
|
"display": "5 or more times a week"
|
|
} ],
|
|
"text": "5 or more times a week"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93030-5",
|
|
"display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
} ],
|
|
"text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93031-3",
|
|
"display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
} ],
|
|
"text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30122-8",
|
|
"display": "I choose not to answer this question"
|
|
} ],
|
|
"text": "I choose not to answer this question"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63586-2",
|
|
"display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
} ],
|
|
"text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 121160,
|
|
"unit": "/a",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "/a"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76437-3",
|
|
"display": "Primary insurance"
|
|
} ],
|
|
"text": "Primary insurance"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA6350-8",
|
|
"display": "Private insurance"
|
|
} ],
|
|
"text": "Private insurance"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "67875-5",
|
|
"display": "Employment status - current"
|
|
} ],
|
|
"text": "Employment status - current"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA17956-6",
|
|
"display": "Unemployed"
|
|
} ],
|
|
"text": "Unemployed"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "82589-3",
|
|
"display": "Highest level of education"
|
|
} ],
|
|
"text": "Highest level of education"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30192-1",
|
|
"display": "High school diploma or GED"
|
|
} ],
|
|
"text": "High school diploma or GED"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56799-0",
|
|
"display": "Address"
|
|
} ],
|
|
"text": "Address"
|
|
},
|
|
"valueString": "1082 Weissnat Arcade"
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93033-9",
|
|
"display": "Are you worried about losing your housing?"
|
|
} ],
|
|
"text": "Are you worried about losing your housing?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "71802-3",
|
|
"display": "Housing status"
|
|
} ],
|
|
"text": "Housing status"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA30189-7",
|
|
"display": "I have housing"
|
|
} ],
|
|
"text": "I have housing"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "63512-8",
|
|
"display": "How many people are living or staying at this address?"
|
|
} ],
|
|
"text": "How many people are living or staying at this address?"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 5,
|
|
"unit": "{#}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{#}"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "54899-0",
|
|
"display": "Preferred language"
|
|
} ],
|
|
"text": "Preferred language"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA43-5",
|
|
"display": "English"
|
|
} ],
|
|
"text": "English"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93034-7",
|
|
"display": "Have you been discharged from the armed forces of the United States?"
|
|
} ],
|
|
"text": "Have you been discharged from the armed forces of the United States?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "93035-4",
|
|
"display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
} ],
|
|
"text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "32624-9",
|
|
"display": "Race"
|
|
} ],
|
|
"text": "Race"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA4457-3",
|
|
"display": "White"
|
|
} ],
|
|
"text": "White"
|
|
}
|
|
}, {
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "56051-6",
|
|
"display": "Do you consider yourself Hispanic/Latino?"
|
|
} ],
|
|
"text": "Do you consider yourself Hispanic/Latino?"
|
|
},
|
|
"valueCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "LA32-8",
|
|
"display": "No"
|
|
} ],
|
|
"text": "No"
|
|
}
|
|
} ]
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:3185d695-9c68-b026-7016-703fef2697ec",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "3185d695-9c68-b026-7016-703fef2697ec",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sdoh-assessment", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-survey" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "survey",
|
|
"display": "Survey"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "76504-0",
|
|
"display": "Total score [HARK]"
|
|
} ],
|
|
"text": "Total score [HARK]"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:a35bb239-f8ac-7bff-b88b-f214190a5f3a"
|
|
},
|
|
"effectiveDateTime": "2001-02-14T20:19:02+01:00",
|
|
"issued": "2001-02-14T20:19:02.153+01:00",
|
|
"valueQuantity": {
|
|
"value": 0,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:0ae49e80-0d81-9645-fd5c-91308ecb6a5d",
|
|
"resource": {
|
|
"resourceType": "Procedure",
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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:f98041e8-7cc8-271f-7ad6-9c76dbabc4fc"
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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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"insurance": [ {
|
|
"focal": true,
|
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"coverage": {
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|
"reference": "#coverage",
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|
"display": "Humana"
|
|
}
|
|
} ],
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"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",
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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": "449411000124106",
|
|
"display": "Admission to skilled nursing facility (procedure)"
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} ],
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"text": "Admission to skilled nursing facility (procedure)"
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},
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|
"servicedPeriod": {
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"start": "2001-12-31T22:21:03+01:00",
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"end": "2002-01-21T22:36:03+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": "21",
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"display": "Inpatient Hospital"
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|
} ]
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},
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"encounter": [ {
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"reference": "urn:uuid:03953477-a9d6-c447-630e-3619837beb97"
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} ]
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}, {
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"sequence": 2,
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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": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "25675004",
|
|
"display": "Patient transfer to skilled nursing facility (procedure)"
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|
} ],
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"text": "Patient transfer to skilled nursing facility (procedure)"
|
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},
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"servicedPeriod": {
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"start": "2001-12-31T22:21:03+01:00",
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"end": "2002-01-21T22:36:03+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": "21",
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"display": "Inpatient Hospital"
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} ]
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}
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}, {
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"sequence": 3,
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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://snomed.info/sct",
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|
"code": "63332003",
|
|
"display": "History AND physical examination (procedure)"
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|
} ],
|
|
"text": "History AND physical examination (procedure)"
|
|
},
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|
"servicedPeriod": {
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|
"start": "2001-12-31T22:21:03+01:00",
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|
"end": "2002-01-21T22:36:03+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": "21",
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"display": "Inpatient Hospital"
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} ]
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},
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"net": {
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"value": 431.40,
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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_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": 86.28,
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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": {
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"value": 345.12,
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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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"amount": {
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"value": 431.40,
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}
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}, {
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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_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": 431.40,
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"currency": "USD"
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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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"amount": {
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"value": 0,
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|
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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": 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": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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"code": "315639002",
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|
"display": "Initial patient assessment (procedure)"
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|
} ],
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"text": "Initial patient assessment (procedure)"
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},
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"start": "2001-12-31T22:21:03+01:00",
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},
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "21",
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"display": "Inpatient Hospital"
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|
} ]
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},
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"value": 431.40,
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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_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": 86.28,
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"currency": "USD"
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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_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": 345.12,
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}
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}, {
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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": 431.40,
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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": 431.40,
|
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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",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 0,
|
|
"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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"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://snomed.info/sct",
|
|
"code": "228869008",
|
|
"display": "Manual wheelchair (physical object)"
|
|
} ],
|
|
"text": "Manual wheelchair (physical object)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2001-12-31T22:21:03+01:00",
|
|
"end": "2002-01-21T22:36:03+01:00"
|
|
},
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|
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "21",
|
|
"display": "Inpatient Hospital"
|
|
} ]
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|
},
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|
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"currency": "USD"
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},
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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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|
} ]
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},
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"amount": {
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"value": 0.0,
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|
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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": {
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"value": 0.0,
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}
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}, {
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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": 0.00,
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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_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": 0.00,
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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_bene_ptb_ddctbl_amt",
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|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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},
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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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|
"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_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
"sequence": 6,
|
|
"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",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://snomed.info/sct",
|
|
"code": "370789001",
|
|
"display": "Development of individualized plan of care (procedure)"
|
|
} ],
|
|
"text": "Development of individualized plan of care (procedure)"
|
|
},
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|
"servicedPeriod": {
|
|
"start": "2001-12-31T22:21:03+01:00",
|
|
"end": "2002-01-21T22:36:03+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": "21",
|
|
"display": "Inpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
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|
"value": 431.40,
|
|
"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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|
},
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|
"amount": {
|
|
"value": 86.28,
|
|
"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_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 345.12,
|
|
"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_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 431.40,
|
|
"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_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
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|
},
|
|
"amount": {
|
|
"value": 431.40,
|
|
"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": 7,
|
|
"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": "410401003",
|
|
"display": "Nursing care/supplementary surveillance (regime/therapy)"
|
|
} ],
|
|
"text": "Nursing care/supplementary surveillance (regime/therapy)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2001-12-31T22:21:03+01:00",
|
|
"end": "2002-01-21T22:36:03+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "21",
|
|
"display": "Inpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
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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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"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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"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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"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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}
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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_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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} ]
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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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"display": "Inpatient Hospital"
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} ]
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},
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"value": 299.34,
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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_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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}
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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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"value": 239.47199999999998,
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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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}
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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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"amount": {
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"value": 0,
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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_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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} ]
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|
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|
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} ],
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},
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"display": "Inpatient Hospital"
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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_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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} ]
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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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"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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"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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|
|
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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_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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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_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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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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"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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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"display": "Medical care"
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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": "Inpatient Hospital"
|
|
} ]
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|
},
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},
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|
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
|
|
"display": "Line Beneficiary Coinsurance Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 132.734,
|
|
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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_prvdr_pmt_amt",
|
|
"display": "Line Provider Payment Amount"
|
|
} ]
|
|
},
|
|
"amount": {
|
|
"value": 530.936,
|
|
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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_sbmtd_chrg_amt",
|
|
"display": "Line Submitted Charge Amount"
|
|
} ]
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|
},
|
|
"amount": {
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|
|
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|
}
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|
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|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
|
"amount": {
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|
|
"currency": "USD"
|
|
}
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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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|
|
"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": 22,
|
|
"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": "409023009",
|
|
"display": "Professional / ancillary services care (regime/therapy)"
|
|
} ],
|
|
"text": "Professional / ancillary services care (regime/therapy)"
|
|
},
|
|
"servicedPeriod": {
|
|
"start": "2001-12-31T22:21:03+01:00",
|
|
"end": "2002-01-21T22:36:03+01:00"
|
|
},
|
|
"locationCodeableConcept": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
|
|
"code": "21",
|
|
"display": "Inpatient Hospital"
|
|
} ]
|
|
},
|
|
"net": {
|
|
"value": 431.40,
|
|
"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": 86.28,
|
|
"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": 345.12,
|
|
"currency": "USD"
|
|
}
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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": "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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"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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"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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"display": "Line Beneficiary Coinsurance Amount"
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"display": "Line Provider Payment Amount"
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"display": "Line Allowed Charge Amount"
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"code": "91251008",
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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": "AMB"
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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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|
"code": "185347001",
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|
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|
} ],
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|
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|
} ],
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|
"subject": {
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|
"reference": "urn:uuid:50390ac6-8c15-46f2-3b23-767f52a2e80c",
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|
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|
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
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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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|
"individual": {
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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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|
"system": "http://snomed.info/sct",
|
|
"code": "6525002",
|
|
"display": "Dependent drug abuse (disorder)"
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|
} ]
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|
} ],
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|
"location": {
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|5e756e0c-7c6b-37c0-8bd5-eebe86c41e5e",
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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}
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} ],
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"reference": "Location?identifier=https://github.com/synthetichealth/synthea|5e756e0c-7c6b-37c0-8bd5-eebe86c41e5e",
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"display": "ASSOCIATED PHYSICIANS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH IS"
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},
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"claim": {
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"reference": "urn:uuid:b02fd104-798c-f09a-dd61-3598953d4326"
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},
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"outcome": "complete",
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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|9999985895"
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},
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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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"insurance": [ {
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"focal": true,
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"coverage": {
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"reference": "#coverage",
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"display": "Humana"
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}
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} ],
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},
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"display": "Medical care"
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} ],
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},
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"locationCodeableConcept": {
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"code": "21",
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} ]
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},
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"net": {
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"value": 431.40,
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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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} ]
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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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"system": "http://terminology.hl7.org/CodeSystem/adjudication",
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} ],
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},
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"amount": {
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},
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"net": {
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"value": 74.58,
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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": {
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|
"value": 14.916,
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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": {
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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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"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": 74.58,
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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_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": 74.58,
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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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"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_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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"category": {
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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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"amount": {
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"value": 211.38,
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"currency": "USD"
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}
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} ],
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"payment": {
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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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},
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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:d082327a-61f8-5be2-04f7-87007cb977e5",
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"resource": {
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"resourceType": "Provenance",
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"id": "d082327a-61f8-5be2-04f7-87007cb977e5",
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"meta": {
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"display": "Dr. Elvin140 Marks830"
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"text": "Transmitter"
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"display": "STANFORD HEALTH CARE"
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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": "Provenance"
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}
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} ]
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}
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