15350 lines
494 KiB
JSON
15350 lines
494 KiB
JSON
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"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": "2021-05-22T00:13:45+02:00",
|
|
"end": "2021-05-22T00:28:45+02:00"
|
|
},
|
|
"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"
|
|
} ]
|
|
}
|
|
} ]
|
|
} ],
|
|
"total": [ {
|
|
"category": {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
} ],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 347.38,
|
|
"currency": "USD"
|
|
}
|
|
} ],
|
|
"payment": {
|
|
"amount": {
|
|
"value": 168.464,
|
|
"currency": "USD"
|
|
}
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "ExplanationOfBenefit"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec",
|
|
"resource": {
|
|
"resourceType": "Encounter",
|
|
"id": "8bea2d5d-f366-a451-ba08-d77f859459ec",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter" ]
|
|
},
|
|
"identifier": [ {
|
|
"use": "official",
|
|
"system": "https://github.com/synthetichealth/synthea",
|
|
"value": "8bea2d5d-f366-a451-ba08-d77f859459ec"
|
|
} ],
|
|
"status": "finished",
|
|
"class": {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
|
|
"code": "AMB"
|
|
},
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "410620009",
|
|
"display": "Well child visit (procedure)"
|
|
} ],
|
|
"text": "Well child visit (procedure)"
|
|
} ],
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873",
|
|
"display": "Johnny786 Vince741 Schoen8"
|
|
},
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|
"participant": [ {
|
|
"type": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
|
|
"code": "PPRF",
|
|
"display": "primary performer"
|
|
} ],
|
|
"text": "primary performer"
|
|
} ],
|
|
"period": {
|
|
"start": "2021-06-26T00:13:45+02:00",
|
|
"end": "2021-06-26T00:28:45+02:00"
|
|
},
|
|
"individual": {
|
|
"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599",
|
|
"display": "Dr. Regenia619 Bosco882"
|
|
}
|
|
} ],
|
|
"period": {
|
|
"start": "2021-06-26T00:13:45+02:00",
|
|
"end": "2021-06-26T00:28:45+02:00"
|
|
},
|
|
"location": [ {
|
|
"location": {
|
|
"reference": "Location?identifier=https://github.com/synthetichealth/synthea|6e3d04a3-9064-33e4-b8b5-63bb468d7629",
|
|
"display": "UNITED MEDICAL CARE LLC"
|
|
}
|
|
} ],
|
|
"serviceProvider": {
|
|
"reference": "Organization?identifier=https://github.com/synthetichealth/synthea|4e56c7ec-99e5-3023-8e4f-95ad18a03f06",
|
|
"display": "UNITED MEDICAL CARE LLC"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Encounter"
|
|
}
|
|
}, {
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|
"fullUrl": "urn:uuid:37cbb2e9-be35-9763-af10-70ee637d697e",
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"resource": {
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"resourceType": "Observation",
|
|
"id": "37cbb2e9-be35-9763-af10-70ee637d697e",
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"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-height" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
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|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8302-2",
|
|
"display": "Body Height"
|
|
} ],
|
|
"text": "Body Height"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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},
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"encounter": {
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|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
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|
},
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|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
|
|
"issued": "2021-06-26T00:13:45.770+02:00",
|
|
"valueQuantity": {
|
|
"value": 54.8,
|
|
"unit": "cm",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "cm"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
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|
}
|
|
}, {
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|
"fullUrl": "urn:uuid:f5305b10-48ea-02b6-b95e-76a929630682",
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"resource": {
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"resourceType": "Observation",
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"id": "f5305b10-48ea-02b6-b95e-76a929630682",
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
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|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "72514-3",
|
|
"display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
|
|
} ],
|
|
"text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
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|
},
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|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
|
|
"issued": "2021-06-26T00:13:45.770+02:00",
|
|
"valueQuantity": {
|
|
"value": 2,
|
|
"unit": "{score}",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "{score}"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:a86a1042-84b6-d703-883d-2348197333bf",
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|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "a86a1042-84b6-d703-883d-2348197333bf",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-weight" ]
|
|
},
|
|
"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": "29463-7",
|
|
"display": "Body Weight"
|
|
} ],
|
|
"text": "Body Weight"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
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|
},
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|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
|
|
"issued": "2021-06-26T00:13:45.770+02:00",
|
|
"valueQuantity": {
|
|
"value": 5.2,
|
|
"unit": "kg",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "kg"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:8dd7c896-79ce-0bf4-2cbc-6c74bf21a5ae",
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|
"resource": {
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|
"resourceType": "Observation",
|
|
"id": "8dd7c896-79ce-0bf4-2cbc-6c74bf21a5ae",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/pediatric-weight-for-height" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "77606-2",
|
|
"display": "Weight-for-length Per age and sex"
|
|
} ],
|
|
"text": "Weight-for-length Per age and sex"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
|
|
},
|
|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
|
|
"issued": "2021-06-26T00:13:45.770+02:00",
|
|
"valueQuantity": {
|
|
"value": 83.356,
|
|
"unit": "%",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "%"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:49492073-1b0b-63e0-d2c9-206ed053f783",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "49492073-1b0b-63e0-d2c9-206ed053f783",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/head-occipital-frontal-circumference-percentile" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "8289-1",
|
|
"display": "Head Occipital-frontal circumference Percentile"
|
|
} ],
|
|
"text": "Head Occipital-frontal circumference Percentile"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
|
|
},
|
|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
|
|
"issued": "2021-06-26T00:13:45.770+02:00",
|
|
"valueQuantity": {
|
|
"value": 25,
|
|
"unit": "%",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "%"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:7a729a24-e482-fb19-c945-18ece5c87cfc",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "7a729a24-e482-fb19-c945-18ece5c87cfc",
|
|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-head-circumference" ]
|
|
},
|
|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
|
|
"display": "Vital signs"
|
|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "9843-4",
|
|
"display": "Head Occipital-frontal circumference"
|
|
} ],
|
|
"text": "Head Occipital-frontal circumference"
|
|
},
|
|
"subject": {
|
|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
|
|
},
|
|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
|
|
"issued": "2021-06-26T00:13:45.770+02:00",
|
|
"valueQuantity": {
|
|
"value": 38.08,
|
|
"unit": "cm",
|
|
"system": "http://unitsofmeasure.org",
|
|
"code": "cm"
|
|
}
|
|
},
|
|
"request": {
|
|
"method": "POST",
|
|
"url": "Observation"
|
|
}
|
|
}, {
|
|
"fullUrl": "urn:uuid:ddb29814-0673-6dc7-e699-8fd3276a6ce6",
|
|
"resource": {
|
|
"resourceType": "Observation",
|
|
"id": "ddb29814-0673-6dc7-e699-8fd3276a6ce6",
|
|
"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:a7a285c0-4714-dd3c-4837-8719c9b67873"
|
|
},
|
|
"encounter": {
|
|
"reference": "urn:uuid:8bea2d5d-f366-a451-ba08-d77f859459ec"
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|
},
|
|
"effectiveDateTime": "2021-06-26T00:13:45+02:00",
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} ]
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"resourceType": "Coverage",
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} ]
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"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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"value": "99999999999"
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},
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"display": "UNITED MEDICAL CARE LLC"
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|
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|
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|
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|
} ],
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|
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|
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|
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|
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},
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"code": "vital-signs",
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} ],
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"system": "http://loinc.org",
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"code": "8289-1",
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"display": "Head Occipital-frontal circumference Percentile"
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} ],
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"text": "Head Occipital-frontal circumference Percentile"
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},
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"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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"code": "%"
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},
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"code": "9843-4",
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} ],
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},
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"code": "cm"
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}
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},
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"url": "Observation"
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}
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-blood-pressure" ]
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},
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} ]
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} ],
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"code": "85354-9",
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} ],
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},
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} ],
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"value": 66,
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"code": "8480-6",
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} ],
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},
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"value": 97,
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}
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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": "9279-1",
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},
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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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"display": "UNITED MEDICAL CARE LLC"
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},
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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 Provider Payment Amount"
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"display": "Line Submitted Charge Amount"
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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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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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"display": "Line Processing Indicator Code"
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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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|
|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "133",
|
|
"display": "Pneumococcal conjugate PCV 13"
|
|
} ],
|
|
"text": "Pneumococcal conjugate PCV 13"
|
|
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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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"display": "Line Provider Payment Amount"
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} ]
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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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"value": 136.00,
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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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},
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"format": {
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"system": "http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode",
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"code": "urn:ihe:iti:xds:2017:mimeTypeSufficient",
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"display": "mimeType Sufficient"
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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": "DocumentReference"
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"display": "UNITED MEDICAL CARE LLC"
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"display": "UNITED MEDICAL CARE LLC"
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"reference": "urn:uuid:35820d65-eed1-2954-e6eb-babeaabcc923"
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"reference": "urn:uuid:f3652776-2dd2-a07a-4a3f-b80717915f12"
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"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
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"reference": "urn:uuid:fe1aba3a-2922-fe74-2e8e-f37f846e7cc8"
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"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
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} ]
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"code": "119",
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} ],
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},
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"code": "10",
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"display": "IPV"
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} ],
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},
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}
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"code": "20",
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}
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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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"code": "133",
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"display": "Pneumococcal conjugate PCV 13"
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} ],
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"text": "Pneumococcal conjugate PCV 13"
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},
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"value": 136.00,
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}
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"system": "http://snomed.info/sct",
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"code": "430193006",
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"value": 369.50,
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}
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} ],
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"total": {
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"value": 1186.30,
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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:d8a5fe4c-11be-b033-ff35-8111998f4594",
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"subject": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599"
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599"
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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": "Medicaid"
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"display": "Medicaid"
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} ]
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} ],
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"value": "87e01d1a-dbf1-cab7-7793-075fb2f33499"
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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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"created": "2021-10-30T00:28:45+02:00",
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"insurer": {
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"display": "Medicaid"
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},
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"provider": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599"
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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|6e3d04a3-9064-33e4-b8b5-63bb468d7629",
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"display": "UNITED MEDICAL CARE LLC"
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},
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"claim": {
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"reference": "urn:uuid:87e01d1a-dbf1-cab7-7793-075fb2f33499"
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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|9999942599"
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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": "Medicaid"
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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": "410620009",
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|
"display": "Well child visit (procedure)"
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|
} ],
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|
"text": "Well child visit (procedure)"
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|
},
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|
"servicedPeriod": {
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|
"start": "2021-10-30T00:13:45+02:00",
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"end": "2021-10-30T00:28:45+02:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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},
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"encounter": [ {
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"reference": "urn:uuid:962cfa87-5151-d1e3-dad0-8fe2d57ddd41"
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} ]
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
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|
"display": "Medical care"
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|
} ]
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|
},
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"productOrService": {
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "49",
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|
"display": "Hib (PRP-OMP)"
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|
} ],
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|
"text": "Hib (PRP-OMP)"
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|
},
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|
"servicedPeriod": {
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|
"start": "2021-10-30T00:13:45+02:00",
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"end": "2021-10-30T00:28:45+02:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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|
},
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|
"net": {
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|
"value": 136.00,
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"currency": "USD"
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},
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"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": 27.200000000000003,
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|
"currency": "USD"
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}
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|
}, {
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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|
"display": "Line Provider Payment Amount"
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|
} ]
|
|
},
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|
"amount": {
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|
"value": 108.80000000000001,
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|
"currency": "USD"
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|
}
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|
}, {
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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|
"display": "Line Submitted Charge Amount"
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|
} ]
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|
},
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|
"amount": {
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|
"value": 136.00,
|
|
"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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|
"amount": {
|
|
"value": 136.00,
|
|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
|
},
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|
"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
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|
}
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|
}, {
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|
"category": {
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|
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
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|
"sequence": 3,
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|
"informationSequence": [ 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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"code": "119",
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"display": "rotavirus, monovalent"
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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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"display": "Line Beneficiary Coinsurance Amount"
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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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"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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"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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}
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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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"code": "1",
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"display": "Medical care"
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} ]
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"system": "http://hl7.org/fhir/sid/cvx",
|
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"code": "10",
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"display": "IPV"
|
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} ],
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"text": "IPV"
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},
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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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"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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"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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"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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"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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|
|
"display": "DTaP"
|
|
} ],
|
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|
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|
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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_bene_ptb_ddctbl_amt",
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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": "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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|
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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_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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|
"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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|
|
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|
|
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|
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
}, {
|
|
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
|
|
"code": "1",
|
|
"display": "Medical care"
|
|
} ]
|
|
},
|
|
"productOrService": {
|
|
"coding": [ {
|
|
"system": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
|
|
},
|
|
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|
|
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|
|
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|
|
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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|
"code": "19",
|
|
"display": "Off Campus-Outpatient Hospital"
|
|
} ]
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|
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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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"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": 295.6,
|
|
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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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"amount": {
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"value": 369.50,
|
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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",
|
|
"display": "Line Allowed Charge Amount"
|
|
} ]
|
|
},
|
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"amount": {
|
|
"value": 369.50,
|
|
"currency": "USD"
|
|
}
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|
}, {
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
|
|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
|
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},
|
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"amount": {
|
|
"value": 0,
|
|
"currency": "USD"
|
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}
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}, {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
|
|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
|
|
"display": "Line Processing Indicator Code"
|
|
} ]
|
|
}
|
|
} ]
|
|
} ],
|
|
"total": [ {
|
|
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|
|
"coding": [ {
|
|
"system": "http://terminology.hl7.org/CodeSystem/adjudication",
|
|
"code": "submitted",
|
|
"display": "Submitted Amount"
|
|
} ],
|
|
"text": "Submitted Amount"
|
|
},
|
|
"amount": {
|
|
"value": 1186.30,
|
|
"currency": "USD"
|
|
}
|
|
} ],
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/head-occipital-frontal-circumference-percentile" ]
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"code": "vital-signs",
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} ],
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"system": "http://loinc.org",
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"code": "8289-1",
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"display": "Head Occipital-frontal circumference Percentile"
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} ],
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"text": "Head Occipital-frontal circumference Percentile"
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},
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"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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"code": "%"
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},
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} ],
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},
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"code": "cm"
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}
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},
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"url": "Observation"
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}
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}, {
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"fullUrl": "urn:uuid:2cede333-c91d-385c-3001-279b30c04f82",
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-blood-pressure" ]
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},
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} ],
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"code": "85354-9",
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} ],
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},
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} ],
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"value": 75,
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"code": "8480-6",
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} ],
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"text": "Systolic Blood Pressure"
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},
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"value": 99,
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}
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} ]
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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": "133",
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"diagnosisReference": {
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"reference": "urn:uuid:a82fcb9d-b732-c257-f99a-ec2dfb817d0a"
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},
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"type": [ {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
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"code": "principal"
|
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} ]
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} ]
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} ],
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"insurance": [ {
|
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"focal": true,
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"coverage": {
|
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"reference": "#coverage",
|
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"display": "Medicaid"
|
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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://snomed.info/sct",
|
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"code": "410620009",
|
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"display": "Well child visit (procedure)"
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} ],
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"text": "Well child visit (procedure)"
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},
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"start": "2022-01-28T23:13:45+01:00",
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"end": "2022-01-28T23:28:45+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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"encounter": [ {
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"reference": "urn:uuid:e1b2c182-cf0a-09fc-94ea-e7f393be3fed"
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} ]
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}, {
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"sequence": 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://hl7.org/fhir/sid/cvx",
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"code": "10",
|
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"display": "IPV"
|
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} ],
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"text": "IPV"
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},
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"start": "2022-01-28T23:13:45+01:00",
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"end": "2022-01-28T23:28:45+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": 136.00,
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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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"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": 108.80000000000001,
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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": 136.00,
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"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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"display": "Line Allowed Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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}
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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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} ]
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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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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
|
|
"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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"end": "2022-01-28T23:28:45+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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},
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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": {
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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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}
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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"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": 136.00,
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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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"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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},
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "20",
|
|
"display": "DTaP"
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|
} ],
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|
"text": "DTaP"
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|
},
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"start": "2022-01-28T23:13:45+01:00",
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"end": "2022-01-28T23:28:45+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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"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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"display": "Line Provider Payment 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_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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"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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"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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|
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
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|
"display": "Medical care"
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|
} ]
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|
},
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"productOrService": {
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"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "133",
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|
"display": "Pneumococcal conjugate PCV 13"
|
|
} ],
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|
"text": "Pneumococcal conjugate PCV 13"
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|
},
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|
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|
"start": "2022-01-28T23:13:45+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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"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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"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": 108.80000000000001,
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|
"currency": "USD"
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}
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}, {
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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|
"display": "Line Submitted Charge Amount"
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|
} ]
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},
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"amount": {
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|
"value": 136.00,
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|
"currency": "USD"
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|
}
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|
}, {
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"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
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|
"display": "Line Allowed Charge Amount"
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|
} ]
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|
},
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|
"amount": {
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|
"value": 136.00,
|
|
"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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|
}, {
|
|
"sequence": 6,
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|
"informationSequence": [ 5 ],
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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|
"code": "1",
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|
"display": "Medical care"
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|
} ]
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|
},
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|
"productOrService": {
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|
"coding": [ {
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|
"system": "http://hl7.org/fhir/sid/cvx",
|
|
"code": "08",
|
|
"display": "Hep B, adolescent or pediatric"
|
|
} ],
|
|
"text": "Hep B, adolescent or pediatric"
|
|
},
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|
"servicedPeriod": {
|
|
"start": "2022-01-28T23:13:45+01:00",
|
|
"end": "2022-01-28T23:28:45+01:00"
|
|
},
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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": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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|
} ]
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|
},
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|
"net": {
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|
"value": 136.00,
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|
"currency": "USD"
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},
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"category": {
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"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
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|
"display": "Line Beneficiary Coinsurance Amount"
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|
} ]
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},
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"amount": {
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|
"value": 27.200000000000003,
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|
"currency": "USD"
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}
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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": 108.80000000000001,
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|
"currency": "USD"
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}
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|
}, {
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|
"category": {
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|
"coding": [ {
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|
"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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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": {
|
|
"value": 136.00,
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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": 136.00,
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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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"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": 7,
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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"display": "Medical care"
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} ]
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},
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"productOrService": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "314529007",
|
|
"display": "Medication review due (situation)"
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|
} ],
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"text": "Medication review due (situation)"
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},
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"servicedPeriod": {
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"start": "2022-01-28T23:13:45+01:00",
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"end": "2022-01-28T23:28:45+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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} ],
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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": 816.80,
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}
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} ],
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"payment": {
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"amount": {
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"value": 544.0,
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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:44c47092-2848-c3e1-f493-5a8f58759404",
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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": "44c47092-2848-c3e1-f493-5a8f58759404"
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} ],
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"code": "AMB"
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},
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "410620009",
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|
"display": "Well child visit (procedure)"
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|
} ],
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"text": "Well child visit (procedure)"
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} ],
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"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873",
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"display": "Johnny786 Vince741 Schoen8"
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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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} ],
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} ],
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"end": "2022-04-30T00:28:45+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|9999942599",
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"display": "Dr. Regenia619 Bosco882"
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}
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} ],
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"period": {
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},
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"location": {
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"display": "UNITED MEDICAL CARE LLC"
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}
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} ],
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"serviceProvider": {
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"display": "UNITED MEDICAL CARE LLC"
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}
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},
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} ],
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"code": {
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"code": "8302-2",
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} ],
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"text": "Body Height"
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},
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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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} ],
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"system": "http://loinc.org",
|
|
"code": "29463-7",
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|
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|
|
} ],
|
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|
},
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|
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|
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|
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|
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|
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|
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|
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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-weight-for-height" ]
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|
},
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|
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|
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|
|
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|
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|
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|
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|
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|
} ],
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|
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|
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|
|
"code": "77606-2",
|
|
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|
|
} ],
|
|
"text": "Weight-for-length Per age and sex"
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|
},
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|
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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": "%"
|
|
}
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|
},
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|
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|
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|
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|
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|
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|
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|
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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": "8289-1",
|
|
"display": "Head Occipital-frontal circumference Percentile"
|
|
} ],
|
|
"text": "Head Occipital-frontal circumference Percentile"
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|
},
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|
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|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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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": "%"
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|
}
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|
},
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|
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|
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|
"url": "Observation"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:ac14abf4-bd74-9e74-d0dd-825c0601fcfa",
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|
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|
"id": "ac14abf4-bd74-9e74-d0dd-825c0601fcfa",
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|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-head-circumference" ]
|
|
},
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|
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|
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|
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|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
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|
"code": "vital-signs",
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|
"display": "Vital signs"
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|
} ]
|
|
} ],
|
|
"code": {
|
|
"coding": [ {
|
|
"system": "http://loinc.org",
|
|
"code": "9843-4",
|
|
"display": "Head Occipital-frontal circumference"
|
|
} ],
|
|
"text": "Head Occipital-frontal circumference"
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|
},
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|
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|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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|
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|
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|
"value": 45.34,
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|
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|
"system": "http://unitsofmeasure.org",
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|
"code": "cm"
|
|
}
|
|
},
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|
"request": {
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|
"method": "POST",
|
|
"url": "Observation"
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|
}
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|
}, {
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|
"fullUrl": "urn:uuid:1eea174f-157f-0257-ba73-fe3abce43816",
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"resource": {
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|
"resourceType": "Observation",
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|
"id": "1eea174f-157f-0257-ba73-fe3abce43816",
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|
"meta": {
|
|
"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-blood-pressure" ]
|
|
},
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|
"status": "final",
|
|
"category": [ {
|
|
"coding": [ {
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|
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
|
|
"code": "vital-signs",
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|
"display": "Vital signs"
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|
} ]
|
|
} ],
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|
"code": {
|
|
"coding": [ {
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|
"system": "http://loinc.org",
|
|
"code": "85354-9",
|
|
"display": "Blood pressure panel with all children optional"
|
|
} ],
|
|
"text": "Blood pressure panel with all children optional"
|
|
},
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|
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|
"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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"effectiveDateTime": "2022-04-30T00:13:45+02:00",
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|
"component": [ {
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|
"code": {
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|
"coding": [ {
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|
"system": "http://loinc.org",
|
|
"code": "8462-4",
|
|
"display": "Diastolic Blood Pressure"
|
|
} ],
|
|
"text": "Diastolic Blood Pressure"
|
|
},
|
|
"valueQuantity": {
|
|
"value": 76,
|
|
"unit": "mm[Hg]",
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|
"system": "http://unitsofmeasure.org",
|
|
"code": "mm[Hg]"
|
|
}
|
|
}, {
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|
"code": {
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|
"coding": [ {
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|
"system": "http://loinc.org",
|
|
"code": "8480-6",
|
|
"display": "Systolic Blood Pressure"
|
|
} ],
|
|
"text": "Systolic Blood Pressure"
|
|
},
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|
"valueQuantity": {
|
|
"value": 103,
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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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"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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"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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"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": "http://snomed.info/sct",
|
|
"code": "430193006",
|
|
"display": "Medication Reconciliation (procedure)"
|
|
} ],
|
|
"text": "Medication Reconciliation (procedure)"
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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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} ]
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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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"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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"display": "Line Processing Indicator Code"
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} ]
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}
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} ]
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"code": "principal"
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"supportingInfo": [ {
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"sequence": 1,
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"category": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
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"code": "info"
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} ]
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},
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"valueReference": {
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"reference": "urn:uuid:9a0548d4-e82f-fa82-1a66-f666050dab04"
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}
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} ],
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"insurance": [ {
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"sequence": 1,
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"focal": true,
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"coverage": {
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"display": "Medicaid"
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}
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} ],
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"item": [ {
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"sequence": 1,
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"productOrService": {
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"coding": [ {
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"system": "http://snomed.info/sct",
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|
"code": "410620009",
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|
"display": "Well child visit (procedure)"
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|
} ],
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"text": "Well child visit (procedure)"
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},
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"reference": "urn:uuid:258878af-43bc-f73b-ab6e-dc85d43ad25b"
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} ]
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}, {
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"sequence": 2,
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"productOrService": {
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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "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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"net": {
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|
"value": 136.00,
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"currency": "USD"
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}
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} ],
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"total": {
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|
"value": 272.80,
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"currency": "USD"
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}
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},
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"request": {
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"method": "POST",
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"url": "Claim"
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}
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}, {
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"fullUrl": "urn:uuid:1d69d8cd-8a95-6c03-d480-04e25c85c563",
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"resource": {
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"resourceType": "ExplanationOfBenefit",
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"id": "1d69d8cd-8a95-6c03-d480-04e25c85c563",
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"contained": [ {
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"resourceType": "ServiceRequest",
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"id": "referral",
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"status": "completed",
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"intent": "order",
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"subject": {
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"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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},
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"requester": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599"
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},
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"performer": [ {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599"
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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": "Medicaid"
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},
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"beneficiary": {
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"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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},
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"payor": [ {
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"display": "Medicaid"
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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": "860b1c97-6919-b31f-152a-38321b47b29a"
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}, {
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"system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
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"value": "99999999999"
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} ],
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"status": "active",
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"type": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/claim-type",
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"code": "professional"
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} ]
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},
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"use": "claim",
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"patient": {
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"reference": "urn:uuid:a7a285c0-4714-dd3c-4837-8719c9b67873"
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},
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"billablePeriod": {
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"start": "2023-04-29T00:28:45+02:00",
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"end": "2024-04-29T00:28:45+02:00"
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},
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"created": "2023-04-29T00:28:45+02:00",
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"insurer": {
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"display": "Medicaid"
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},
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"provider": {
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"reference": "Practitioner?identifier=http://hl7.org/fhir/sid/us-npi|9999942599"
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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|6e3d04a3-9064-33e4-b8b5-63bb468d7629",
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"display": "UNITED MEDICAL CARE LLC"
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},
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"claim": {
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"reference": "urn:uuid:860b1c97-6919-b31f-152a-38321b47b29a"
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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|9999942599"
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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": "Medicaid"
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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",
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"code": "410620009",
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"display": "Well child visit (procedure)"
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|
} ],
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"text": "Well child visit (procedure)"
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},
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"servicedPeriod": {
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"start": "2023-04-29T00:13:45+02:00",
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"end": "2023-04-29T00:28:45+02:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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|
"display": "Off Campus-Outpatient Hospital"
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} ]
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},
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"encounter": [ {
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"reference": "urn:uuid:258878af-43bc-f73b-ab6e-dc85d43ad25b"
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} ]
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}, {
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"informationSequence": [ 1 ],
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
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"code": "1",
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"display": "Medical care"
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|
} ]
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},
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"productOrService": {
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"coding": [ {
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"system": "http://hl7.org/fhir/sid/cvx",
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|
"code": "140",
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|
"display": "Influenza, seasonal, injectable, preservative free"
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|
} ],
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"text": "Influenza, seasonal, injectable, preservative free"
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},
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"servicedPeriod": {
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"start": "2023-04-29T00:13:45+02:00",
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"end": "2023-04-29T00:28:45+02:00"
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},
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"locationCodeableConcept": {
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"coding": [ {
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"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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"code": "19",
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"display": "Off Campus-Outpatient Hospital"
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|
} ]
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},
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"net": {
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"value": 136.00,
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"currency": "USD"
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},
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"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": 27.200000000000003,
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"currency": "USD"
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}
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}, {
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
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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": 108.80000000000001,
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"currency": "USD"
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}
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"category": {
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"coding": [ {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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"code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
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"display": "Line Submitted Charge Amount"
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} ]
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},
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"amount": {
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"value": 136.00,
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"currency": "USD"
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}
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"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": 136.00,
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"currency": "USD"
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}
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"code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
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|
"display": "Line Beneficiary Part B Deductible Amount"
|
|
} ]
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},
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|
"amount": {
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"value": 0,
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"currency": "USD"
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}
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"category": {
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"system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
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|
"code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
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|
"display": "Line Processing Indicator Code"
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|
} ]
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|
}
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|
} ]
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} ],
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"total": [ {
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"code": "submitted",
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"display": "Submitted Amount"
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} ],
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},
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"value": 272.80,
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}
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} ],
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"payment": {
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}
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}
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},
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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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"fullUrl": "urn:uuid:6ab97e60-7680-d052-04f7-89701b836dd7",
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"id": "6ab97e60-7680-d052-04f7-89701b836dd7",
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"meta": {
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"profile": [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-provenance" ]
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"reference": "urn:uuid:0e677b21-56c8-aa47-3146-7f52bcfb7d87"
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"reference": "urn:uuid:e0cef9d3-d847-a416-f7a9-196712aef7d2"
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"url": "Provenance"
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} ]
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}
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